Mental health at work

New thinking about mental health and employment.

Bob Grove, Jenny Secker, Patience Seebohm (editors). Oxford: Radcliffe Publishing, 2005 (xxii + 162 pp). ISBN 1 85775 769 6.

Sigmund Freud stated that the pillars of psychological wellbeing are love and work. Unfortunately, it is work that is most sensitive to the impact of mental illness. Return to work has always been a key aim of psychiatric rehabilitation. At times, the illness proves a turning point in life, motivating positive change and greater achievement of life goals. The majority of patients get back to work, but for a minority, work outcomes are bleak. The impact of treatment has even, at times, been negative (for instance, conventional neuroleptics causing the “zombie-like” state of drug-induced Parkinsonism).

The response of the community and employers has been an even greater handicap. Discrimination is still rife. Given that 49% of the population will develop a mental illness in their lifetime, the impact of the new dismissal laws may create enormous social upheaval in Australia.

Very little has been written about employment and mental health, and I keenly looked forward to reading New thinking about mental health and employment, only to be seriously disappointed by contributions from the editors.

The book opens with the statement, “Most people who suffer from periods of mental ill health would like to work and yet less than 20% are in employment”. This statistic applies to sufferers of chronic schizophrenia, not mental illness in general. While it is totally legitimate for the editors to concentrate on people with chronic psychoses, they should say they are doing so.

After all, the editors indicate that they advise government authorities on employment for the mentally ill. Yet only one is identified professionally as a professor of nursing, and the other two, for reasons I cannot discern, omit their professional backgrounds.

The editors argue that the “all-pervasive medical model” has created a system that actually excludes people from employment. This is a tired old argument. There is much in public psychiatry that deserves profound censure, but doctors’ alleged lack of concern about employment is not one of them (the capacity to do much about it may be another story). It is absolutely undeniable that effective medical treatment will improve the capacity of patients to return to work, and hence will facilitate any assistance given by employment services.

Much more justifiably, the editors tackle therapeutic nihilism in schizophrenia, again with anecdotes of doctors telling patients they will never work again, where this was manifestly wrong and damaging. The issue is difficult as people with schizophrenia often do have a poor outcome, but I also see patients who continue to work at the highest professional levels despite suffering chronic illness. Rather than pointing to the heterogeneity of schizophrenia, and how differently patients may be affected, the editors run the old argument that schizophrenia does not actually have a poor prognosis if only clinicians developed better attitudes. A new paradigm “of intervening to halt and reverse the journey to exclusion” is the way to go. Who could disagree?

What saves the book is that most of its content comes from contributors other than the editors. There is a great deal of useful information. The biographical accounts, feedback on services, and perspectives of the users are both articulate and enormously instructive, although recounted treatment experiences are often tragic.

Chapters such as “What do service users want?” and “What’s kept me working?” are invaluable. The evidence of “what works” is well presented but the conclusions fall down by attempting to generalise where there are enormous differences in individual needs. Accounts of actual services and how to develop interventions are useful.

On balance, this book is worth reading because it contains information that will assist clinicians to help patients with chronic psychoses get back to work.

Nicholas A KeksProfessor of Psychiatry, Monash University, Melbourne, VIC