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The mental health conversation hasn't gone too far, but has it become too narrow?

In the second blog of this series on mental health and the UK welfare system, Annie Irvine and Cassie Lovelock highlight the need for a more holistic approach to understanding the interplay of work, welfare and mental health.

Recent months have seen a series of policy statements highlighting the problem of economic inactivity due to long-term ill health, among which mental health problems make up a high proportion. These ministerial speeches have included accusations that we have a ‘sick note culture’, that people are having overexaggerated responses to the ‘everyday challenges and worries of life’, and suggestions that people with common mental health problems of anxiety and depression do not need the levels of benefit support currently being made available.

At the ESRC Centre for Society and Mental Health, we are carrying out qualitative research investigating the ways in which people’s lived experience of distress shapes their interactions with work and the welfare system. This includes secondary analysis of archived research data, and new qualitative longitudinal research which is taking an in-depth lifecourse perspective on the interplay of work, welfare and mental health.

Both of these studies show clearly that the role mental health problems play in people’s work trajectories over time is highly contextual. For some people, at some points in their life, mental distress is absolutely the key factor which makes work outright impossible. But our analysis reveals that we cannot treat mental health problems as a discrete, sole or independent factor in how people’s working lives play out over the long term. Mental health problems very rarely occur ‘out of nowhere’ and the things that have happened to people leading up to their distress and the wider social and economic context of their lives when they become unwell, are also fundamental shapers of work and welfare outcomes.

The lifestories of participants in our studies repeatedly show the impacts of early childhood adversities, such as physical or emotional abuse, parental illness or being a young carer, on people’s ability to complete schooling and gain an initial foothold in the world of work. Into adulthood, employment trajectories are shaped and constrained by experiences of domestic violence, relationship breakdown, lone parenthood, homelessness, poverty and displacement. Moreover, structural influences include barriers to training and further education, limited access to transport, not to mention the challenges of insecure work, limited labour market opportunities and inflexible employers. The additional stress of a punitive welfare system dominated by compliance and the threat of financial sanctions also plays a significant and counterproductive role.

These multiple non-health factors impact and impede people’s capacity for work alongside their concurrent and interconnected experiences of mental distress. When we consider what is keeping people out of employment, it is in many cases impossible to separate the role of mental ill health from the complex web of adversities that are shaping people’s work trajectories over time.

To give one (alarmingly common) example, domestic violence, lone parenthood and homelessness often come together to make working impossible for a woman with young children. This woman will also, very likely, be experiencing some combination of anxiety, depression, post-traumatic stress and possibly long-term trauma from her own adverse childhood experiences. Yet when approaching the benefits system for support, this woman (if her children are over the age of 24 months) has essentially two options: to present as fit for work, or as mentally ill. Whilst the latter may be a true reflection of how she feels at that moment in time, it does not tell the whole story – it denies the complexity of her lived experience, individualises her ‘problem’ and – important to the welfare to work agenda – it also clouds out the full range of challenges for which she may need support in order to move towards a position where she feels able to consider re-engagement with paid employment.

Therefore, whilst we strongly dispute the statements of politicians who argue that the mental health conversation has gone too far, we do suggest that – in the context of the welfare system – the mental health conversation may have got too narrow.

Current policy approaches around mental health and employment tend towards a decontextualised and medicalised view of mental illness, whereby the mental health problem is positioned as an ‘entity’ to be treated, and worklessness is framed (by benefit categorisation and assessment processes) as a problem of ill health to be either accommodated in the workplace or validated as grounds for benefit receipt. There is no doubt that people’s distress is real. We cannot emphasise that enough. However, our detailed and holistic enquiry into people’s lived experiences makes it clear that mental health is not the only barrier that people face when trying to obtain or retain a foothold in the world of paid work. It is both insufficient, and a misrepresentation of people’s circumstances, to treat it as a standalone problem.

The upshot of this alternative analysis of the problem is that we need a much more holistic approach to understanding and assessing work capability. A system that allows people to tell their whole story and permits all aspects of that story to be considered when evaluating their capacity for work at a given time. A welfare system that takes only a narrow and medicalised conceptualisation of mental illness into account, when assessing people’s capacity for work, is insufficient to understand the multifaceted web of challenges, barriers and contingencies that shape people’s ability to “start, stay and succeed” in work (as the current catchphrase goes).

The lifestories of participants in our studies are incredibly complex and, whilst there are some common themes, each is unique. Therefore, as has been noted by others writing on poverty, adversity and distress:

Where disadvantages cluster together, the causal priority of one over another may be less important (and impossible to determine) than the qualitatively distinct type of hardship that emerges from their assemblage.– (Desmond & Western, 2018)

Therefore, rather than attempting to pinpoint the independent role of mental health problems in work capability, the crucial point is to understand that mental distress arises from and operates within a complex and multifaceted web of social, relational and economic circumstances, which weave together in ways that pose substantial barriers – practical, logistical, economic, cognitive and emotional – to sustained employment. Jones and colleagues articulate this perfectly, when they write that we need to understand labour market engagement:

... not solely through the psychological lens of trauma, but also as socioenvironmental contexts that powerfully shape vocational and financial trajectories and outcomes … There are considerable risks of centering individual-level psychopathology (if and) when contexts and determinants at higher ecological levels (meso, macro) in fact play causal roles in shaping outcomes.– Jones et al., 2024

In short, we need to understand work capability as more than a health issue. Currently, the UK welfare assessment system positions ill health as the singular frame through which a person’s worklessness is understood and legitimised (or not). But, in many cases, this narrow medicalised framing risks an incomplete understanding of the problem – and in the case of mental distress, may lead us to look in the wrong place for solutions. Without losing the important ground gained in understanding and awareness of mental health problems, and without for a moment dismissing people’s lived experience of distress, we need a broadening of perspective on how we understand the shapers and constrainers of work capacity and how we – in turn – design, locate and fund related intervention and support.

In this story

Cassandra  Lovelock

Cassandra Lovelock

Qualitative Research Assistant

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