There is “no health without mental health” (Ki-Moon, 2010, para.2; World Health Organisation, 2005, p.11) and this is why this topic has become at the heart of many discussions. The World Health Organisation (1948) in WHO (2003), approaches this concept holistically and defines mental health as the balance between all the aspects of life; “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity” (p.100). Barry & Jenkins (2007) add that mental health is an attitude that fosters in the individual a sense of control, hope, optimism and the capacity to build and sustain relationships in the society. Thus, mental health is said to be “a measure of how people, organizations, and communities think, feel, and function, individually and collectively (Keyes, 2007, in Mc Collam, Mukkala, O’Sullivan, Rowe, & Stengard, 2008, p.6). For this reason, Phillips (2008) affirms that the
well-being and mental well-being, in particular, [are] a new frontier in the fight for social justice in the creation of a society which is fair; communities which offer the individual dignity and respect; the evolution of a people confident in their diversity.
Given that mental illness has become the leading cause of disability in the European Community, with more than 130 million people expected to experience some kind of mental illness in their life (EUFAMI, 2004), many nations are acknowledging that they cannot ignore mental health and mental illness in their communities and workplaces anymore. As Gauci (2010) argues, countries that adopt “legislations, policies and systems that protect vulnerable citizens, including people with mental illness reflects a society that respects and cares for its people” (p.7).
Extensive is the research carried out about mental illness, but for a common terminology of the different types of disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM) has been developed. The DSM-IV states that
mental disorders are conceptualized as a clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.
(American Psychiatric Association, 2000, p.xxxi)
Thus, for behaviour to be considered a disorder, it must be originally caused by a “behavioural, psychological, or biological dysfunction in the individual” (American Psychiatric Association, 2000, p.xxxi). Conversely, expectable responses to particular events (e.g. the death of significant other), deviant behaviour (e.g. political, religious, and sexual behaviour), conflicts between the individuals and the society are not mental disorders. These only fall into the latter category when “the deviance or conflict is a symptom of a dysfunction in the individual” (American Psychiatric Association, 2000, p.xxxi), as aforementioned.
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There is vast spectrum of mental disorders, each having their specific criteria, but for general use, Goldberg & Huxley (1992) categorize mental disorders in two ways, namely, common mental illnesses and severe mental illnesses. The former are mostly evident in the community whilst the latter refers to disorders which are more common amongst people who receive mental illness services and thus, contrary to the above, may need special care to convalesce. Goldberg & Huxley (1992) add that severe mental illnesses “are associated with much greater social disability and are much less likely to resolve spontaneously with time.” (p.5)
At this point it is important to understand that despite its severity, mental illness does not lead to mental disability, and the two are different from each other. As aforesaid, mental illness impacts a person’s behavior and feelings, however, the symptoms can be managed (Inclusion Europe and Mental Health Europe, 2007). On the other hand, mental disability, also known as intellectual disability refers to people who have difficulties in learning and understanding and whose skills “in areas such as cognition, language, motor, and social abilities can be permanently impaired” (Inclusion Europe and Mental Health Europe, 2007, p.2). Therefore, mental illness is not a disability, but the difficulties derived from the illness, can result in functional disability (Richmond, 2011). Functional disability is defined by the WHO (1976) as
disability in which functional limitation and/or impairment is a causative factor, is defined as an existing difficulty in performing one or more activities which, in accordance with the subject’s age, sex and normative social role, are generally accepted as essential, basic components of daily living, such as self-care, social relations, and economic activity.
(para. 1.2 iii)
2.2 Employment
In its simplest definition, work means the “exchange of labour for wages” (Danto, n.d, p.14). But employment has always had a higher value for humanity. Indeed the Ancient Greeks held that work formed part of the “sphere of necessity” (Haralambos & Holborn, 2004, p.619). Notwithstanding the changes and revolutions that the world went through, work still remained “a defining value of our culture” (p.12) and this is so because the need to work is deeply rooted in “our psychology and social existence” (Dante, n.d, p.14).
Work can take many forms but its benefits are rather homogenous. Cameron & Conley (2010, in Topp, 2010) assert that work is meaningful because it connects individuals to their values and to their community. It is also acknowledged that good working experiences affect the individual’s wellbeing and development, leading them to adopt more positive perspectives and attitudes. This is further reinforced by Finch & Moxley (2003), who declare that “employment offers much promise to people and is fundamental to their development as fully realized human beings” (p.10). Underlining all this is the truth that employment is a human right. Hence, all people “have the right to work; to free choice of employment; just and favourable conditions of work and protection against unemployment” (Article 23, 1948, in United Nations, n.d). In the convention on the rights of persons with Disabilities, the United Nations (2006) accentuate that people who experience disability are also entitled to “human rights and fundamental freedoms in the political, economic, social, cultural, civil or any other field” (Article 2) and discrimination is proscribed, including the failure to provide reasonable accommodations for those who need it.
This is sustained by Bassett & Llyod (1997) in Bassett, Bassett & Llyod (2001), when they claim that “involvement in paid employment is a significant life occupation for many people and is a realistic goal for people who have experienced a mental health disorder” (para.2).
2.3 The benefits of employment for people experiencing mental illness
Therefore, work is not only important to maintain good mental health but also to enhance the improvement of those who are experiencing mental health difficulties. “Enabling people to retain or gain employment has a profound effect on more life domains than almost any other medical or social intervention” (Boardman, Grove, Perkins & Shepherd, 2003,p.467). This is so because employment harbours inclusion, yields a sense of security, happiness and comfort; a sense of living needed for recovery. Recovery from mental illness is a reality nowadays and it has become a goal for many people. Recovery does not mean that symptoms disappear, but it is all about getting on with life beyond the disability (Deegan, 1988). Having experienced it herself, Deegan (1988) adds
recovery does not refer to an end product or result. It does not mean that my friend and I were ‘cured’. In fact our recovery is marked by an ever-deepening acceptance of our limitations. But now, rather than being an occasion for despair, we find that our personal limitations are the ground from which spring our own unique possibilities
(p.56).
Work is central to the process of recovery (Canadian Mental Health Association, 2005; HM Government, n.d). This is so because it provides both the financial means for living and also latent benefits. Olsheski & Schelat (n.d) assert that employment is beneficial because it provides structures to daily activities, an identity, a sense of achievement, socioeconomic status and a sense of belonging. This is sustained through Hertzberg’s theory who believed that work meets human needs in two ways. The acquisition of a salary, the working conditions and interpersonal relationships established at the working site make up the hygiene factors. According to Herzberg, their absence creates dissatisfaction in the individual, but does not lead him to feel satisfied and motivated (Herzberg, 1959, in Gawel, 1997). At this level, any changes towards job performance are only short-lived. Conversely, motivator factors produce long-term positive outcomes which appear to be a consequence of job satisfying events such as appraisals, achievements and advancements (Herzberg, 1959, in Gawel, 1997). Job satisfaction and longer job tenure have been found by Resnick & Bond, (n.d) in URBIS (2007) to be co-related.
As it is acknowledged above, the benefits of employment for people with mental health difficulties are various, yet the barriers for work are still a reality. In fact, people experiencing mental health difficulties rank low in employment when compared to other disabled groups (Organisation for Economic Co-operation and Development, 2009; Duncan & Peterson, 2007), despite that many of them have the aspirations to work (HM Government, n.d). In addition, Catalano et al (1990) claim that people with mental illness are many often employed in part-time work, characterized by little pay and possible insecurities. The reason behind this is that accessibility of the workplace most often is only associated with the adaptation of the physical environment through the use of various adaptive equipment, and adaptation of the social and emotional environment is often neglected. Accessibility also means opening up the labour market to facilitate participation in the economic activity and social functioning. While it is true to say that the illness often acts as an obstacle (Frado, 1993) and may create problems for the employee whilst in employment, but the working environment also lacks the tools to accommodate “their interests, abilities and support needs” (Bill et al, 2006, in URBIS, 2007, para.4.3.4).
Some of the most severe forms of mental illness have their onset in late adolescence and beginning of young adulthood, whilst others strike in middle adulthood. As a matter of fact, both a person’s education and working life could be significantly impacted; resulting in fewer credentials which are needed for employability and the disruption of employment for those who are already employed (WHO, n.d, in Richmond Foundation, 2011). Penrose-Wall & Bateman (2007) in URBIS (2007) add that people with mental illness may experience a downfall in their confidence, motivation and social skills as a result of the episodic nature of the illness, and as a matter of fact, their “employment is understandably disrupted” (para.4.3.1). Once again, a person’s educational and occupational attainment may be at a disadvantage (Robdale, 2008). Moreover, the level of severity of the illness has been linked to unemployment, with a percentage as high as 85% for people with severe mental illness (Crowther et al 2001, in Duncan & Peterson, 2007). Additionally, the medication used to treat the illness may pose some difficulties for the person whilst on the job. Some of which include drowsiness, tremors, blurred vision, nausea, agitation, bladder problems, dry mouth amongst others (National Institute of Mental Health, 2008). Despite the struggle to cope with the illness, people may also have to deal with bad financial issues that arise when their ability to work is affected. Thus in order to make ends meet, people with mental illness may force themselves back to work before they would have gained their health (Canadian Mental Health Association, 2005). In the light of such delicate situations, Cappe (1999) avows that
it is no longer enough to do the right thing, but we must also ensure that we are doing things right. It is no longer sufficient to be a place where people work-the workplace itself must be built around the people and give them the support they need
(para.1)
A place of work that is built around people is one that welcomes diversity. “It signals the enthusiastic acceptance of the value to organizations of workforces that are diverse in terms of gender, age [and] (dis)ability… (Jackson & Joshi, 2001, in Arnold, Burnes, Cooper, Patterson, Robertson & Silvester, 2005,p.35). Mental illness is no longer a rare condition but it is has become one of the most common causes of disability with the World Health organization claiming that by the year 2020, depression will become the second leading cause of premature death and disability (Canadian Mental Health Association, 2005). In the light of these statistics, employers cannot fail to acknowledge the concepts of mental health and mental illness in their workplace. It is time to do away with the misconceptions that people with mental illness are violent and have low intellectual abilities. To the contrary, they are usually the victims of violence and their intelligence and abilities are not dissimilar to the rest of the populace (Frado, 1993). Many people experiencing mental illness are able to work, want to work and can carry out their job successfully (Cook & O’Day, 2006).
2.4 Stigma
But stigma has the power to erode this willingness. As HM Government (n.d) outlines, barriers to employment and sustainability of employment for people experiencing mental health difficulties are also found to be derived from society itself, with stigma acting as one of the major obstructions. Stigma can be described as
severe social disapproval due to believed or actual individual characteristics, beliefs or behaviors that are against norms, be they economic, political, cultural or social. It is characterized by a lack of knowledge about mental health, fear, prejudice and discrimination.
(Mc Daid, 2008, para.2.1)
These are also the prevailing beliefs amongst certain employers, who are still afraid to employ and support people with mental illness (Waghorn & Lloyd, 2005, in URBIS, 2007; Canadian Mental Health Association, 2005; Mc Daid, 2011). They may have “unwarranted fears and see persons with psychiatric disabilities as unskilled, unproductive, unreliable, violent or unable to handle workplace pressures” (Fenton & Payne, 2005, p.8). But mental illness does not always encroach with the worker’s job performance or it may affect the ability to work only for a certain time, during which, some limitations may arise (Frado, 1993). These may include “consistent late arrivals or frequent absences, decreased productivity, frequent complaints of fatigue or unexplained pains, difficulty concentrating, working excessive overtime and expressions of strange or grandiose ideas, amongst others” (Fenton & Payne, 2005, p.7). In view of these limitations, the untrained employer and colleague may fail to recognize mental illness, and interpret inappropriate behavior negatively, thinking that their work mates are violent, dangerous and erratic (Harnois & Gabriel, 2000). This is further manifested in incorrect and discriminating behavior as people with mental illness are often given insulting names, refusals by their colleagues to work with them and not considered for promotions (Fenton & Payne, 2005).
Just like students who tend to see themselves as ‘bright’ or ‘dull’ according to their teachers’ definition of them, people with mental illness may come to believe that they are truly ‘no good’. This negative general idea about mental illness is then often internalized within the individual himself, leading to self-stigma. Self-stigma refers to the negative feelings about oneself; manifesting itself into feelings of hopelessness, difference and unworthiness (Barnes, Duncan & Peterson, 2008). As a matter of fact, people with mental illness may not be so willing to try new job tasks, opportunities and promotions (Frado, 1993). The media is said to have a profound effect in all this. As findings indicate,
Coverage of mental health issues that was biased, negative, sensationalized, or incorrect was seen as contributing to the negative stereotypes that surround mental illness. These in turn influence the attitudes and behavior of the people who believe them, including people with experience of mental illness.
(Barnes et al, 2008, p.60)
2.5 Maintaining employment
In the essence of a holistic policy that targets mental illness, Maltese citizens who experience functional disability due to mental illness can in the meantime benefit from the provisions of the Equal Opportunities (Persons with Disability) Act (2000). In the light of this situation, Dr. C. Pace, social policy consultant and lecturer at the University of Malta, divulges that
while we clearly and strongly distinguished mental health problems from intellectual or learning disability, I think it would be a disservice to persons with mental health problems if we fail to tell them and society that, in the case of a long-term impairment, they can have specific and important legal rights.
(in a personal communication, January 2011, regarding how this was dealt with in a recent project)
Therefore, under the provisions of this article, people with a mental illness who exhibit functional disability are to enjoy the protection against discrimination as well as reasonable accommodations in their working environment. It is the latter concept which encapsulates the commitment of employment corporations to create the necessary structures, be them legal, administrative or institutional, which facilitate both employability and adaptability at the place of work for persons with mental illness. As the Transition Strategies, LLC (2010) contend,
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Although the law prohibits discrimination against mentally disabled persons in the workplace, the economic impact of these numbers is so compelling that regardless of any concerns about disability discrimination lawsuits, employers cannot afford to ignore the problem. Even when a problem worker is fired, the odds are excellent that his or her replacement will be one of the remaining….The solution?
(para.2)
In view of these emerging needs, the workforce is pressured to understand that people with mental illness may have certain needs to be met. However this does not imply that their skills and capabilities are of a substandard (Boardman, Grove, Perkins & Shepherd, 2003). Employers and colleagues are suggested to increase their knowledge about mental illness and respond with anti-discriminative measures and reasonable adjustments so that people with mental illness can function in the working environment like their colleagues counterparts. Indeed, Frado (1993) claims that “the antidote to stigma in the workplace is for the environment to be positive, encouraging and welcoming” (p.6). However, there are people whose experience of mental illness does not affect their ability to work (Frado, 1993), and thus may not need help to maintain their job.
Accommodation measures are in effect some of the tools which the employer can use to help bring about adjustments to the workplace. “An accommodation is any change in the work environment or in the way things are customarily done that enables an individual with a disability to enjoy equal employment opportunities”, claims the U.S. Equal Employment Opportunity Commission, (2002, para.2). Research shows that that workers with mental health difficulties does not necessarily cause any excessive burden on the employer (Diksa and Rogers,1996; Tetrick & Toney, 2002) but with practical modifications in the social and organizational structure, they can act capably and competently in their work and as contributors to the society (Frado, 1993).
Starting a new job may be a stressful experience to people with mental illness (Mc Kee, 1996). This is so because they may be faced with certain challenges and thus may need accommodation to maintain the employment. In fact, Shankar (2005), states that keeping a job is more exigent than obtaining it. This is sustained by a personal disclosure of a person who says that
Because of my medication, it’s really difficult for me to keep to a schedule… I mean to get up on time. My employer is happy with my work and as long as I put in my eight hours, she doesn’t mind if I don’t make it on time every day. This is the first job I’ve been able to keep without being fired for lateness.
(as cited in Frado,1993, p.15)
People experiencing mental illness may find it hard to follow the demands of daily living such as waking up early but a positive and constructive principle like this provides a strong foundation for accommodation. Additional policies include allowing people to work flexible hours or to work at home, enable frequent breaks, allow workers to shift work hours to attend hospital appointments, allow telephone calls to doctors or others for support, and permit a self-paced workload amongst others (Loy, n.d).
A working place is not solely run by the manager, but people at different levels constitute different roles and all are important in the running of the company. Thus, even the attitude of the supervisors, colleagues and other staff adds to providing a climate that supports accommodation. Given that people still make negative connotations with mental illness, it is important to address these misconceptions by educating staff and colleagues about these illnesses, its course and consequences. Moreover, supervisors closely working with the employees should be given training on how to improve one’s approach and teaching methods. Examples include giving constructive feedback, offering praise and providing direction (Frado, 1993).
Nonetheless, in order for the employer to provide such accommodation measures tailored for the specific needs of the employee, people need to disclose about their difficulties but this is not an easy task given the stigma that exists. They may think that the advantages of disclosing about these difficulties are very little compared to the disadvantages and thus they may choose to remain silent. Others may have worked so much to restore their health that they do not want to be categorized as disabled (Frado, 1993). But as Mc Kee (1996) claims, the employee does not necessarily have to give a specific diagnosis of his illness. To the contrary, she suggests people with mental illness to “focus on how the disability impacts upon [their] ability to do the job and what positive steps can be taken to accommodate [their] needs” (p.7). Such a disclosure can potentially reduce tension whilst increasing support and help on the job. Employing people with mental illness is not only beneficial for their health but as the Canadian Mental Health Association, 2005 outlines, it also “bring[s] a new perspective to the workplace, and a new level of sensitivity among all employees to one another” (p.23).
The supported employment scheme is another benchmark in the commitment to provide people with mental illness the necessary services to find and keep employment. It was originally known as the place and train approach which embarked on the idea that people with mental illness shall first be placed in the job and then offered training (EUSE, n.d). The job coach has the imperative role to provide the service users with the necessary support to perform ordinary work requirements such as accompanying them to and from work, training and education of the employee, advocacy, assistive technology, behavioral training skills and other support to make the employment a positive experience both for the employee and the employer (Parent, 2004). The European Union of Supported employment defines this scheme as “providing support to people with disabilities or other disadvantaged groups to secure and maintain paid employment in the open labour market” (EUSE, n.d, p. 13).
Family members and friends may not be able to help in acquiring the skills needed for employment, but they can be a source of support and hope for people with mental illness along their working life experience. These social support networks are described “as a nexus of interpersonal ties consisting of family, friends, or other individuals who provide some type of support that leads one to believe that he or she is cared for, loved, valued, and belongs to a network with mutual obligations” (Milardo, 1988, in Pernice, 2010, para.2 ). These can aid in making long-term employment a reality (Canadian Mental Health Association, 2005) and recovery a lived-experience (Pernice, 2010).
2.6 The Social Model and Medical Model of disability
The measures outlined above are aimed to provide assistance for people with mental illness in finding and retaining employment in the mainstream workforce. However, as aforementioned, difficulties that arise in this scenario are not only a responsibility of the employee, but also of the society at large. Therefore this calls on the need to not view difficulties as the result of the individual’s disorder only; as anchored in the medical approach, but to also consider societal factors responsible for difficulties encountered (Mor, 2005). This is the social model of disability which “focuses on the complex ways that economic relations, cultural meanings, social practices, and institutional settings participate in the disablement of persons (Mor, 2005, p.22).
This shift in locus on the integration of people with mental illness in the society did not happen instantaneously. Although change in the beliefs, perceptions and attitudes towards mental illness seem to be taking a gradual pace, much improvement has been done along the years. Before the means of acquiring knowledge and information increased, people were not educated about mental health. This goes back to few centuries ago when mental illness was thought to be caused by supernatural forces. They were thought to be ‘moonstruck’ and thus were referred to as ‘lunatic’ (Pritchard, 2006, p.3). In fact, Mount Carmel Hospital, currently responsible of the rehabilitation of mental illness in Malta, was called the Lunatic Asylum in the 1800’s (Savona-Ventura, 2004). These perceptions of madness and possessions lead to the abuse of many people with mental illness. As Cauchi (1999) reported, people with mental illness were beaten and treated badly.
People with mental illness were made to believe that they were incurable and insane and were even denied civil rights (Daub, 2006). This is the medical model which rooted in its teachings has the basic ideology that mental illness is just a “chemical imbalance or a biological malfunction of the brain” (Daub, 2006,p.2). In this period, the mental health practice suggested that people with mental illness who were interested to work should stay away from working in the community. Instead, they were suggested to work in highly protected and isolated settings like the sheltered workshops (Becker & Drake, nd). These gave the individual “the opportunity to work without having to risk competition and failure experiences which, it was assumed, would occur in normal work environments” (Bussone, Cramp, Dakunchak & Rosen, 1993,para.2). Activities in this category were meant to shelter persons from normal problems while exposing them to normal task requirements such as time clocks and supervision (Becker & Drake, n,d). But as years passed by, sheltered workshops became less popular because work was demeaning and it offered no prospects since people always remained in an institutional setting (Bussone et al, 1993). Then focus was shifted on teaching people the necessary skills for employability. This was referred to as the train and place approach in which people mental health difficulties were given training in order to find employment. Once trained, they were free to find themselves a job. However this probability was not plausible since the acquisition of the skills alone were not sufficient to gain and maintain employment (EUSE, n.d).
The concept of supported employment was the last to be introduced but it is the one which offers much promise to people with mental illness as it emphasizes the need for integration into society and engagement in open paid employment. Whereas before, people with mental illness were only seen in the context of health services, now their strengths are being recognized and are considered to be potential contributors to our society (Frado, 1993). Supported employment schemes and accommodation measures both provide the employee with the opportunity to enjoy a working life that best meets their needs.
2.7 The Current situation
It could be that people are no longer beaten and retained due to their illness and sheltered workshops gain less endorsement, yet it is still a struggle for people with mental illness to find and keep jobs. As Gauci, (2010) says, “the lack of flexibility at the work place and the stigma and fears, which still exist in our society; most frequently results in the violations of people’s right to work”(para.5). Unfortunately, circumstances that defy the rights of persons with mental illness are not always given the prominence that they require (Gauci, 2010). Locally, supported employment services are very limited, even if they proved to be successful. In fact, the Richmond Foundation (2009), in Richmond Foundation (2011) asserts that in the year 2009, a total of twenty six persons with mental illness benefited from this scheme. This service has been unavailable for a period of time but is currently in the process of being re-introduced. Also, the Maltese mental health Act needs to be updated as it continuous to result in the violations of the rights of people experiencing mental illness (Ameen, 2009). To further stress this point, Mc Sween (2002) claims that mental health “still receives less government support than general health care” (para.1). Indeed, Gauci (2010) avers that
it is very basic and superficial when a country has policies and legislation which promote community care when in practice community services are inadequate, scare, uncoordinated, understaffed or staffed by persons who are not trained to deal with persons with mental health difficulties in the community.
( para.4)
These support lacking systems are also a major concern to many parents who fear that their children will become unemployed, poor and homeless, “with no one to look after them, rotting away and walking around the village looking dirty and alone”(Calleja, 2010b, para.16).
2.8 Social work and mental illness
Social Work has an imperative role in all this since its core values are crafted to address social problems and challenge social injustices (Johnson & Yanca, 2007). Not only should social workers provide people with mental illness with the support and skills needed to help them overcome disadvantage but also seek to transform the society for the benefit of their clients (Payne, 2005). This is so because the social work profession calls on its associates the need to consider the person in environment as sometimes “there is a tendency to ignore environmental factors responsible for social problems” (Johnson & Yanca, 2007, p.60).
It is this aspect of social work that moves in line with the social model of disability, as it too takes into consideration the society’s attitudes that act as a barrier for people with mental illness to maintain employment. Th
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