Unravelling the rise in mental health-related inactivity
About 4 mins
Dr Annie Irvine, Lecturer in Social Policy and Public Management at the University of York School for Business and Society, argues we need to take a much more holistic approach to understanding capacity for work if we want to tackle mental health-related inactivity.
The Health Foundation is making detailed endeavors to understand the factors underlying the steep rise in mental health-related economic inactivity. This has been against a backdrop of less supportive readings of the situation, such as suggestions that people are ‘overmedicalising everyday challenges’ or exaggerating distress for financial gain. I want to add another dimension to this debate: perhaps we are not looking holistically enough at the problem of economic inactivity, nor the potential policy solutions.
In my 22 years as a qualitative researcher, I have had the privilege of hearing the life stories of numerous people who have experienced mental health problems. I have tried to better understand their journeys between employment, sickness absence and social security benefits. Over and over again these testimonies demonstrate that it is a complex chain of causal events – a multiplicity of interwoven social, relational, economic and structural factors – that cause people to lose their work in the context of mental distress. There is no doubt whatsoever that people’s distress is real, genuine and often severe. However, it is rarely the whole story of why they have struggled to retain or regain employment.
Mental health problems are real, but rarely the whole story
People’s capacity for work is shaped by many factors. This comes through time and time again in people’s own accounts of the barriers they face in returning to the labour market. Research participants, freed from the constraints of the questions in benefit claim forms, or the threatening power structures of the Work Capability Assessment, give nuanced explanations of the intertwined factors that affect their capacity for work. These ‘whole story’ accounts, which we welcome and make space for in qualitative research projects, reveal that mental health is one part of a much bigger picture.
Alongside the physical and emotional symptoms of distress, people tell us about a complex array of other factors that simultaneously limit their capacity for work. These include labour market barriers (low pay, poor work conditions, lack of suitable vacancies); the financial viability of work (‘the benefits trap’); jobseeking conditionality rules constraining opportunities to study and retrain; transport-related issues; age discrimination; citizenship status; lack of formal documentation; digital exclusion; lack of careers guidance; criminal justice system involvement; debt management issues; housing issues or homelessness; parenthood and caring commitments; substance use; and the impact of domestic abuse on their careers, confidence and self-esteem. People also talk about their aspirations and role preferences, wanting support for self-employment, the need for flexible hours and compatible work patterns and locations and, not least, the barriers put up by the punitive welfare system itself.
Welfare conditionality rules pay little recognition to the multitude of personal or social circumstances that might shape or constrain a person’s capacity for work. When dealing with the welfare system, the only real option people are given to explain why it is difficult for them to work is ill health. This leads me to ask whether, in an ever more complex and precarious social world, the administrative category of ill health is ‘doing the work’ for a much wider set of social, structural, relational and economic barriers to employment.
When health is the only part of the story the system will hear
When asked to account for their lack of employment by labour force surveys and the welfare system,poor health is the narrow descriptive framing offered to people. It is the only aspect of a person’s experience the benefit system will hear as valid. So, until the welfare system allows a safer space for people to express the full complexity of their circumstances, the statistics will inevitably show an intractable ‘mental health problem’ in the welfare system.
The Health Foundation’s analysis indicates that people’s wider context matters to their work outcomes, revealing that mental health problems are less of a barrier to employment if a person has higher level qualifications. Previous research has also shown that having a degree, being in a skilled role and working for a large employer make it less likely a person will lose their job when they experience poor mental health. Recent research also reveals that having more flexibility, control and autonomy at work increases the likelihood of retaining one’s job in the face of ill health. What other contextual factors might distinguish those able to sustain employment alongside mental distress from those who are not? Only by going beyond the blunt administrative categories of our current system can we fully understand and respond to this complexity.
I will say it again: people’s distress is real. What I am arguing for is a ‘both-and’ conceptualisation of the issue. For many people who experience mental health problems, there are periods of time when the physical and emotional manifestations of distress do represent the dominant barrier to work. It is also essential to recognise the lived experiences of people who feel their distress will always prevent any type of formal employment and those who strongly believe that work should not be seen as a health outcome. But many people within the welfare system would like to return to work, and too narrow an understanding of their circumstances may result in too narrow solutions. The government’s recent Get Britain Working white paper pledges a huge additional investment in talking therapies. But this must not substitute investment in those wider public services and supports that are the foundation of both good mental health and access to sustainable employment: stable housing, effective transport, affordable and accessible childcare, protection from violence and abuse, and secure jobs with decent employers.
A more holistic understanding of people’s capacity for work
Without losing the important ground gained in understanding and awareness of mental health problems, and without for a moment disregarding or disbelieving people’s lived experience of distress, we need a broader conceptualisation of ‘capacity for work’. As things stand, ill health is the only category the benefit system offers people as a way to explain their complex, multifaceted barriers to work.
If we want to fully understand the problems people face and create effective support for their routes back into employment, we need to look to the wider social determinants of economic inactivity and address them at their source. We need to understand mental distress in context and not simply as a catch-all category or isolated cause of non-employment. We also urgently need to remove the harmful and counterproductive conditionality imposed on people who do not meet health-related criteria. And we need to step away from the stalemate of defining and categorising ‘real’ mental illness and take a much more holistic approach to understanding capacity for work.