WORKING REJUVENATES THE MIND

Effort is never wasted. In societies where employment is the norm, meaningful work meets a range of psychological, emotional and social needs. These are seminal to defining the identity and social status of the individual. Loss of a job involves more than income. The worker loses social relationships, daily structures, and a sense of purpose.

A peer-reviewed study showed that people with a purpose in life live longer.^[1] The converse is equally true. Job loss can be aggravated by anxieties over income-loss and a decline in living standard. Shattered too is the sense of self-esteem since unemployment leads to the erosion of status among friends, family and community. Loss of contact with friends and colleagues and a shrinking social net further isolates the individual. Its bearing on mental health is not uniform and may depend on age, gender and length of unemployment benefits. While job-loss diminishes mental health, reemployment has been demonstrably beneficial.^[2]

According to 2006-estimates, Britain lost 175 million working days to sick leave claimants. Whereas in 1970, only 2% of the working-age population claimed disability benefits, currently 7% claim disability benefits, costing the British economy an additional £100-billion. In the USA, 10% of all social expenditure is allocated to disability benefits, while in Norway the relative magnitude is well over 20%.^[3] Mental health disorders are the main reasons for sick leave claims in developed countries. Within Organization for Economic Cooperation and Development (OECD) countries, mental illness accounts for 35% of all disability benefits.^[4]

Symbiosis of Work and Mental Health

Authorities hypothesize that the workplace environment positively influences mental health in several ways. It furnishes a medium of social interaction and purposeful activity outside the family circle. Working per se gives definition to character and provides structures to the employee’s daily routine. Other advantages include financial security allowing one to contribute meaningfully to oneself, family and society.^[5]

It has been postulated that a symbiotic relationship exists between health and work. Whereas the inability to work is a determinant in the development of mental illness, the act of working promotes mental health and builds a sense of identity. A working environment advances and supports mental and physical wellbeing; it is conducive to productivity and helps mentally ill employees return to work more quickly with fewer recurrent problems. In effect, the employer’s interest is better served because it is the healthy employee who increases output and effectiveness in the workplace.

Just as a job contributes to the health of workers, they in turn contribute to the viability of the businesses. Declining mental health of employees magnifies their deficiencies through the lens of management. Among the short-comings reported are decreased yield and increased accident and injury rates. Loss of cognitive ability results in faulty decision making, deterioration in planning and loss of control. Relationships become strained resulting in conflicts between management, colleagues and clients much to the detriment of employee-employer relationship. Other adverse consequences of mental health problems in the workplace include frequent short-term disability.

Employment Nurtures Mental Health

The adverse impact of unemployment on physical and psychological wellbeing of the individual is well documented.^[6] Current studies indicate that worklessness causes mental health deterioration. Besides, declining mental health is one of the leading causes of sick leave and disability benefits. Common reasons for sick leave is depression and anxiety.^[7] Compounding the problem, many undiagnosed mental health patients are afflicted by other musculoskeletal disorders particularly lower back pain and fibromyalgia. While unemployment has been shown to raise the danger of depressive symptoms twofold over the employed, re-employment has been effective in improving mental wellbeing.^{[8],[9],[10],[11]}

The evidence that unemployment is detrimental to mental health is compelling. According to Dooley, becoming unemployed, inadequately employed or inactive is associated with depression.^[12] The impact of job loss on mental health can occur through financial stress, loss of self-esteem and loss of social contacts. In addition, inactivity and stress related to unemployment is responsible for deterioration in general health and wellbeing.^[13] This cause-effect relationship is oft-times bidirectional: that is, unemployment breeds mental health issues and mental health issues cause unemployment. ^[14][15]

The Curse of Sick Leave

In general, the data show that workers benefit more by staying on the job rather than taking leave of absence as it adversely affects both the employee and the employer.^[16] In their study of the relationship between unemployment and workers’ health, Waddell and Burton have concluded: There is a strong association between worklessness and poor health. This may be partly a health selection effect, but it is also to a large extent cause and effect. There is strong evidence that unemployment is generally harmful to health, including – higher mortality; poorer general health; poorer mental health; higher medical consultation, medication consumption and hospital admission rates...……A sickness certificate……is one of the most powerful, potentially dangerous treatments in a GP’s armamentarium.^[17]

Among other reported findings of Waddell and Burton are: (1) re-employment improves health and increases the self-esteem; (2) health benefits gained from working outweigh the risks; and (3) the positive health effects of working apply to healthy people of working age, people with disabilities, and those in receipt of benefits.^[18]

These findings were buttressed by the findings of Dame Carol Black. She observed: For most people, their work is a key factor in their self-worth, family esteem and identity. So, if they become sick and are not helped quickly enough, they can all too easily find themselves on a downward spiral into long term sickness and a life on benefits. Dame Black has further indicated that the incompatibility of illness with work is a myth and that working does not impede recovery. Hence the prevalent misconception regarding the adverse relationship between work and health has meant that vocational advice by healthcare professionals to patients is generally ill-conceived. ^[19]

The position of Dame Black was supported by an Australian longitudinal study showing that once a person starts certified work absence, they usually slip into long term unemployment. It gets incrementally worse. After six months leave, there is only a 20% chance of remaining in the workforce in five years. During the period of absence, negative effects of worklessness appear. In rather grim perspective, long-term unemployment is equivalent to smoking ten packets of cigarettes per day. For the sick-leave-granting physician, the transparent moral is that sick leave certificates should be issued with due consideration rather than on demand.^[20] The reasons are compelling. Among some of the effects of unemployment on mental health are: (1) steady decline in physical and psychological health; (2) six-fold increase in suicide rate ; (3) interpersonal strains; (4) loss of identity and self esteem ; (5) financial stresses; and (6) steady erosion of the quality of life.^[21]

A study of prolonged time-off for minor injuries has disclosed that keeping people productively employed is good for the individual and society. Ably supporting these findings is the Australasian Faculty of Occupational Medicine. It has asserted that: There is good evidence to suggest that people who are injured and claim compensation for that injury have poorer health outcomes than people who suffer similar injuries but are not involved in the compensation process. The research indicates the importance of psychosocial and financial factors in long-term disability. According to recent evidence, early medical intervention significantly reduced chronicity and long-term disability.^[22] Other organizations have strongly backed these claims. Agewatch reported a direct correlation between unemployment and poor health. In line with their observations, people who were unemployed had poorer physical and mental health. Their hospital stays were longer relative to the employed and had a shorter life span. Conversely, re-employment leads to improved self-esteem, improved general and mental health, and reduced psychological distress and minor psychiatric morbidity, they concluded. Additionally, Agewatch contends that those who are sick should be encouraged to remain in or re-enter the workforce as soon as possible, because of its therapeutic and health benefits. ^{[23],[24],[25]}

In support of this claim The Royal College of Psychiatrists reported that: There is now plenty of compelling evidence that paid or unpaid work is good for the mental and physical wellbeing of the majority of people. Returning to or getting into work actually helps people to recover from a period of mental ill-health…... (P)eople who are unemployed or workless have poorer health than their employed counterparts. Unemployed people visit their GP more, are more likely to be admitted to hospital and have higher death rates.^[26][27]

Employed males generally have lower self-esteem than females. Unemployment data reveal that while mental health deteriorates over time for males and females, the female workers have better recovery. Of greater significance to females, is the quality of the job. At higher occupational skills – professional, managerial - mental health appears to be better than at lower unskilled levels. In other words, the more prestigious the occupation, the better the mental health.^[28]

In toto, expending effort in the work force is productive. Moreover, the rate of decline of mental health is reduced when people work. For males, there are no differential effects with respect to the type of occupation. Males who are out of the labor force have substantially worse mental health than females possibly because activities like family care are acceptable for females, but males. The deterioration rate is influenced by time spent in employment since working inhibits the rate of mental health decline.^[29]

The merits of meaningful effort supersede financial rewards. A review of more than thirty rigorous and longitudinal studies on The Health Benefits of Volunteering found those who volunteer live longer, have greater functional ability and lower rates of depression compared to non-volunteers.^[30].^[31] A 2008-study showed that, volunteering can deliver health benefits both to volunteers and to health service users. … (It) improves …mental health, life satisfaction, the ability to carry out activities of daily living without functional impairment...…….and the ability to cope with one’s own illness. Apparently volunteering stimulates the mind which in turn stimulates the body. It also provides a medium for increased social interaction, sense of purpose and personal accomplishment, resulting in increased self-confidence, reduced depression, happiness and optimism, and a more robust immune system.

Other significant findings are that: (1) older volunteers are the most likely to receive greater benefits from volunteering; (2) the earlier the age of volunteering, the healthier the volunteer later in life; and (3) individuals suffering from chronic pain experienced declines in their pain intensity and decreased levels of disability and depression when they began to serve as peer volunteers for others also suffering from chronic pain.^[32] Fig 1. graphically summarizes the benefits of volunteering.

Therapeutic Value Work on In-Patients

Despite being institutionalized, patients derive therapeutic benefits by being productive. Given work assignments, patients were able to experience… success…..and the sense of being, contributing, productive members of the institutional community. For mental health professionals, creative work is considered satisfying and a valid form psychosocial treatment, an undeniable path to self-actualization.^[33], Even odious drudgery - not creative or self-actualizing – provide a benefit to the individual.^[34] Fig. 2 shows the bio-social needs that must to be met to ensure that one enjoys his full potential or self-actualization.

While a segment of vocational professionals demands that one must be healthy to work, others believe that working promotes healing. Supporting the latter view point is Gendlin. He has indicated that: Getting reconnected to the world is an essential part of the process of getting well. It must not be left until the patient is ready. But to the mentally ill, society can be mesmerizingly conflicting. On the one hand society demands that the mentally ill earn their living while at the same time precluding their participation. These conflicting demands are unhelpful to the mentally ill. Indeed, reconnecting with society through supportive employment programs is a worthwhile solution.^{[35], [36]}

The curative influence of meaningful occupation on mental health has been supported by the observations of vocational professionals. Using schizophrenic subjects, researchers tried to determine whether combining cognitive stimulation with work-therapy could improve occupational competence. They, therefore, evaluated the effects of progressively difficult computerized attention and memory tasks by randomly assigning patients work-therapy alone or cognitive stimulation combined with work-therapy.^[37] The treatments provided ongoing opportunities to incorporate fundamental cognitive benefits into more complex reasoning processes. Because work-therapy alone was found to be clinically efficacious, it provided a reference point for evaluation of cognitive stimulation.^[38],[39] Subsequent evaluation showed that patients undergoing cognitive stimulation together with work-therapy had better executive function and working memory.^[40] As many as 60% of the participants showed substantial improvements: normal memory function jumped from 45% to 77%. The researchers concluded that computer training for cognitive dysfunction can be deployed to treat schizophrenics wishing to engage independent employment. A two-year follow-up study provided confirmatory evidence. It revealed that recipients of combined cognitive stimulation and work-therapy worked significantly longer hours and with higher rates of employment. Although cognitive training alone enhanced vocational performances, patients who melded cognitive training with other rehabilitation methods had sustained productivity. The study further indicated that the efficacy of this approach was due to the synergistic effect which, in turn, created a natural medium for exercising and developing mental proficiency.^[41],[42] Physical evidence of enhancement in executive function following exposure to the dual therapies was supported by functional Magnetic Resonance Imaging (fMRI) studies. Studying subjects performing progressively difficult attention and memory tasks, investigators found that under-functioning cognitive systems of schizophrenics developed a sizable degree of cognitive improvement. This was correlated with observable changes in the frontal lobe of the brain. Another study examining the effect of remunerated work on drug-addicted veterans disclosed that patients on paid-work programs were more likely to initiate outpatient treatment for their addictions. These patients suffered fewer drug and alcohol problems and reported fewer cases of substance-abuse. They also had less incidences of homelessness and incarceration than control subjects.^[43]

Unquestionably, compensation is a motivation to work but the simple joy of working is enough. For people with common health problems, including back pain, stress, depression and high blood pressure just returning to work stimulates recovery.

Katri Saarikivi agrees that work per se can be therapeutic: moreover, the healing value can be maximized if the task is tailored to meet the needs of the individual. In her view, cognitive rehabilitation methods should be designed to provide the mind with stimulation and focus; the mind needs meaningful focus to restore to itself; passive wandering impedes recovery.^[44] For this reason, extended sick leave impedes recovery as it denies the employee the benefit of the stimulating structures of the workplace environment.

Despite the link between work overload, physical/emotional exhaustion and depression, purposeful effort is the wellspring of healing and enduring wellbeing. Because employee depression causes sensitivity to work-overload and susceptibility to fatigue, Saarikivi theorizes that crafting the workload to match mental competence is critical to recovery. Customizing the structures of the workplace environment and work content to the specific needs of the employee is therapeutically more effective. Hence, modifying work therapy in detail and magnitude to fit the employee’s mental disposition can be of greater therapeutic value than simply providing an unstructured work opportunity.^{[45],[46][47]}

The impact of the therapeutic effects of working would be incomplete if the brief biopic of Esso Leete was omitted. Writing in the journal of Hospital Community Psychiatry she recounted: A community program can help develop a predictive daily schedule to offset their chaotic inner existence……Any number of structured activities could satisfy this need, but I have found work – a paying job - to be most helpful. My job gives me something to look forward to everyday, a skill to learn and improve, and an earned income. It is my motivation for getting up every morning, not always an easy task for a psychiatric patient. My hours at work are spent therapeutically as well as productively, for through steady employment I have learned to value myself and trust in my ability to overcome my disease.^[48]

Expanding social networks and enhanced social status are but a few benefits of paid employment. The consensus is that both paid and unpaid employment, including volunteering, that is safe and satisfying is good for health and wellbeing. Monetary compensation is irrelevant.^[49]