This article is the first in a series by Polly Peek addressing the issues of work and mental health from a Marxist perspective. For more information on the concept of dialectics see http://www.marxists.org/glossary/terms/d/i.htm. In this article the term ‘mental health community’ refers to those people experiencing mental illness or distress, and ‘consumer’ refers to those using or having previously used psychiatric services..
The role work plays in the mental health of people experiencing mental illness is complex, with research on the topic appearing somewhat contradictory on the surface, the most prominent contradiction being whether work is overall beneficial or detrimental to well-being and recovery. Research suggests that employment, or engagement in meaningful contribution is a “critical component of the pathway to recovery” (Mental Health Commission, 2001, cited in Duncan and Peterson, 2007) and that the most significant employment challenge for people experiencing mental illness is overcoming structural barriers to attaining work. At the same time, other studies indicate that the correlation between work and wellness is not so clear-cut, and that the kinds of jobs most accessible to the mental health community are also those with the highest likelihood of decreasingwell-being and obstructing recovery. In approaching this conflict through a dialectical analysis, the question of interplay between work and mental health moves from one of ‘is work more beneficial or detrimental to recovery and wellbeing’ to one of ‘how can the contradictions of employment’s simultaneous facilitation and eroding of wellness be resolved’.
To assess how features of work in the broad sense are facilitative or detrimental to recovery and wellbeing, it is first necessary to define these terms. The concept of recovery as a mental health philosophy began in psychiatric rehabilitation establishments in the USA around the early 1990’s. Around the same time, mental health consumer movements in the US and around the world began to shape their definition of recovery, focussing on self-determination and “emphasising the social, economic and political dimensions of recovery” (O’Hagan, 2008). Through its appropriation and development by different groups, recovery became the “first genuinely post-institutional service philosophy” (O’Hagan, 2008; Klos, ND). In the New Zealand context, recovery has been integrated into practise through three models, the recovery approach, recovery competencies for mental health workers, and the recover principles. These principles are closely aligned with the concept of mental health recovery as it was first developed by Anthony (1993) into eight key principles:
Recovery can occur without professional intervention, recovery is the presence of people who believe in and stand by the person in need of recovery, a recovery vision is not a function of one’s theory about the causes of mental illness, recovery can occur even though symptoms reoccur, recovery changes the frequency and duration of symptoms, recovery does not feel like a linear process, recovery from the consequences of the illness is sometimes more difficult than recovery from the illness itself, and recovery from mental illness does not mean that someone was not really ‘mentally ill’ (Anthony, cited in Kelly et al, 2010).
In querying how employment can help or hinder recovery, the above principles will be a reference point as well as the New Zealand Mental Health Commission’s definition of recovery as “living well in the presence or absence of illness”.
Well-being is a concept drawn upon by the World Health Organisation (WHO) in its definition of health as “not merely freedom from disease, but also a state of fulfilment – physically, emotionally, economically and in social relations” (Bellaby, 1999, p15). In the New Zealand context wellbeing is often understood with reference to hauora – Maori understandings and models of health or wellness. One widely used model of wellbeing is Mason Durie’s Whare Tapa Wha model, a diagrammatic representation of wellness utilising the visual of a ‘four walled house’ where each wall is related to one aspect of wellbeing; physical, mental/emotional, social and spiritual. Other Maori models of wellbeing which are less utilised or well-known, possibly for their relative complexity or politicised foundations (Wenn, ND), include Pere’s Te Wheke – the octopus and Durie’s Nga Pou Mana. When discussing the impact of employment on well-being, I will be drawing on concepts within the Whare Tapa Wha model, exploring how work impacts people’s mental emotional/health directly, as well as impacting the social relations and supports, physical or material aspects of the person’s life, and sense of purpose, meaning and world view, all of which influence mental health vicariously.
The belief that productive activity can be beneficial to people experiencing chronic and long term mental illness has been developed over the last two centuries since it was first promoted in psychiatric establishments by French physician Philippe Pinel. Along with implementing other progressive reforms, Pinel was one of the first institution doctors to take a recovery approach, believing his patients could be cured and returned to society. He advocated for “activity rather than idleness and systematic programmes of activity as well as cognitive work to restore reason” (Hunter & Macalpine, 1963; Shorter, 1997 cited in Southern, 2010) and, resultantly, is considered one of the greatest reformers of the mental health care system since its beginning. Today in New Zealand and other Western countries, the value of work in recovery is practically recognised through the maintenance of occupational therapy programs and supported employment services (Duncan and Peterson, 2007; Klos, ND).
As Annie Southern highlights in her thesis “Researchers often work from the ‘given’ that work has a therapeutic impact and underpins economic status and identity” (2010, p121) and it has been argued that an uncritical acceptance of this premise is rooted in the understanding of “compulsory employment as ‘natural’ and ‘normal’” (Southern, p121). This perspective is promoted by a world-view which sees the benefits of work for people with long-term mental illness to be exclusively instrumental, in that it is beneficial only insofar as society attributes values to work and is bound by the social cohesiveness that results from it. I would argue that work is both intrinsically and instrumentally valuable in supporting mental health recovery and wellness.