Employment has the potential to contribute to positive health outcomes for people with serious mental illnesses; however, its analog, long-term unemployment, is a social determinant that has not been consistently recognized for its extremely negative effects on the individual’s recovery and other health outcomes. The fact that unemployment is extremely detrimental to health is still significantly overlooked within behavioral health systems of care. Employment status is currently seen as an acceptable outcome for this group, especially since the advent of evidence based supported employment (IPS), as the myth that employment itself might be “too stressful” for such people to undertake has been contravened by much evidence over the last few decades (Drake & Wallach). However, long-term unemployment for people with mental illness has still not been seen as a major factor in overall treatment planning. An increasing number of programs have implemented IPS programs with success. However, the impact on local systems for people with mental illness has been negligible in terms of overall employment outcomes as far too many remain un or under employed. We suggest a call to action for individuals’ providers and policy makers alike to reduce barriers to employment recognizing that unemployment is very bad for people served and employment is very good.
Substantial evidence exists showing an association between long-term unemployment and poor overall health outcomes, even in the absence of pre-existing conditions. Much of the literature indicates that long term unemployment can lead to mental health symptoms. Long-term unemployment has the potential to be very harmful to ones’ physical and mental health even absent premorbid symptoms. Experiences such as perceived job insecurity, downsizing or workplace closure, and underemployment also have implications for physical and mental health. Such data exists from studies as early as 1938 through the present day.
There is a lot of evidence that work can be good for one’s overall health, including a 2012 systematic review (Rueda, Chambers, et al) that showed that returning to work had positive impacts on health. They showed significant improvement in health after reemployment significant decline in health after continued unemployment Much less attention has been focused on the adverse effect of long-term unemployment. In simple terms, as the title of this article notes: Unemployment is worse for you than employment is good for you.
Policy, research, and service funding have sought to answer the question “If people choose to work, what is the most effective intervention to help people get a job?” We also need to ask, “Since unemployment is so harmful, how can we help more people get a job to reduce their general health risks that impact their quality of life and potentially lifespan?” We need to focus on helping people be successful in getting a job as successful employment for motivated individuals is significantly different from assertively intervening to change a trajectory of unemployment. Highlighting long-term unemployment as a clinical risk factor for mental illness requires an assertive medically necessary response by all direct service staff, even those not directly involved with employment service delivery. This response should be deployed proactively for people who have, or are at risk of having, long-term unemployment, not only in response to a stated desire from someone interested in pursuing work. It is not that people who want to be involved in employment intervention are denied the opportunity to do so, but far too often service providers do not perceive the clinical implications of the person’s situation as a long-term unemployed individual. They tend to adopt a passive approach unless a person specifically requests job placement help. In our experience accessing that help is not something they assess as clinically important and often discourage the person or do not provide support or guidance the person may need.
Most state behavioral health policies neither incentivize employment as an outcome nor sanction service delivery intermediaries within the system that do not impact the employment status of large numbers of clients. The result is that employment is seen as a social or economic problem, rather than as a concomitant serious health risk. Employment advocates cite paid work as providing a role identity, an avenue out of poverty, and an increased social network. These benefits while true, may not seem urgent to service providers, policy makers, or funders. Reframing the issue as to the risks of long-term unemployment not only makes this a critical issue for the well-being of people served by systems, but also points to the major costs of not addressing its potential health consequences.
Two caveats must be kept in mind. Concretely put, being unemployed over a long period is likely worse for one’s general well-being, outweighing the positive value of any one job for any individual. Specific job conditions (e.g., poor working conditions, unfair pay, poor supervision, unhealthy workplaces) can, in fact, be stressful in ways that contribute to physical or psychological morbidity. This challenge can be effectively addressed by assisting people to access jobs that reflect their skills and values and support them in ways that maximize their success (i.e., creating a viable person – job match). In addition, addressing long-term unemployment is not synonymous with mandating work as a requirement for receipt of health care benefits or food support. Assisting an individual’s vocational achievement to prevent the negative impact on this social determinant while using the withdrawal of other social supports which increases the negative impact of corollary social determinants appears self defeating at best.
Low-cost strategies that can be implemented within these systems include reinforcing mental health providers’ commitment to viewing long-term unemployment as a health risk. An initiative implemented by one of the authors in his role as an administrator in a large community mental health center required all clinical staff to address long-term unemployment on treatment plans. This is how agencies require mandatory crisis planning for service plans, even when not specifically requested. This did not mean forcing anyone to seek employment when they did not wish to do so. Rather, it required staff to engage individuals in understanding the potential health impacts of continued unemployment, identifying internal and external barriers faced in rectifying this situation, and developing interventions to help them overcome barriers.
Some ways public systems can enhance employment opportunities includes improving the efforts between mental health systems of care and strictly employment focused systems (VR, Workforce) including joint funding agreements and information protocols that allow for regular updates on mutual clients. Additionally, public policy and funding authorities should ensure that all behavioral health programs include as one performance metric either a specific goal of enhancing employment outcomes for people served or at a minimum provide regular reporting on the employment status of all clients. Transparency and effective dissemination strategies also play a role in countering the negative social consequences associated with long term unemployment. Reporting publicly available information on employment status and employment goals achieved for all the adult clients served on a quarterly basis would help place focus on what is needed to ensure programs make efforts to support employment as part of overall health.
Behavioral health service organizations are in an ideal position to make a positive impact vis-à-vis employment as one social determinant of health. An initial administrative step that can be taken would be requiring all clinical staff to ask people served in terms of what specific employment strategies might be most helpful, even if the person does not explicitly request assistance in employment. Also, oversight and funding bodies could create provider goals addressing unemployment among people served, i.e. first assessing the baseline data of the employment situation of all clients, and subsequently setting targets for improvement since we know that unemployment can positively impact both mental and physical health. Behavioral health direct support staff can be expected and trained to ask on every visit about the client’s interest in working or what the person has been doing to make efforts to get a job /keep your job or find a more fulfilling job. Clinical and other community behavioral health service personnel can be expected to advise people served about the negative effects of remaining in poverty for the entirety of one’s life by remaining under /unemployed and lay out the possible health risks. Finally, underline the seriousness of the organization’s intent to address long term unemployment as a negative social determinant by assisting every client to move closer to employment, whether through vocational counseling, career decision-making, job search, informational interviews, supported employment referral, or intercession with a specific employer. In sum, it is not enough to identify [un]employment as a key social determinant of health without mobilizing actions and commitments to ensuring everyone is given opportunities to pursue competitive employment. We suggest a call to action to reduce barriers to employment since unemployment is very bad for people served and employment is very good.
Drake, R. E. and M. A. Wallach (2020). “Employment is a critical mental health intervention.” Epidemiology and Psychiatric Sciences 29: e178. DOI: 10.1017/S2045796020000906
Rueda, S., Chambers, L, Wilson, M., Mustard, C., Rourke, S., Bayoumi, A. Raboud,J., Lavis, J. (2012). “Association of Returning to Work With Better Health in Working-Aged Adults: A Systematic Review.” American Journal of Public Health 102(3): 541-556