This year's World Mental Health Day, which falls on Oct 10, focuses on the workplace. It's time to consider protection for those who want to work but cannot due to discrimination.
As far as work is concerned, we have come a long way from the elite of ancient Greece who had held it in contempt (they had an underclass and their slaves to toil for them). They thought that life was for leisurely contemplation, and "paid employment", as Aristotle had put it rather disdainfully, would "absorb and degrade the mind".
Through subsequent millennia, the idea of work and the attitude towards it have evolved; it is for most of us today our livelihood, and for many it is also more: Our work is melded into our identity, it buttresses our self-esteem, and it gives us purpose and a sense of belonging to a community.
There is a group, however, who is often excluded from this community. The unemployment rate of people with mental illnesses almost everywhere (including Singapore) is strikingly and disturbingly high - despite having the highest "want to work" rate of any unemployed group. One British survey found that as many as 90 per cent of people with mental illnesses wanted to return to the workplace.
The reasons for this high rate of unemployment are varied and overlapping. For one thing, there is that widespread discrimination that stymies and disables people with mental disorders in so many ways. Studies done on both sides of the Atlantic, as well as in Australia, found that a considerable proportion of people with such health problems reported that they have been fired or forced to resign from their jobs, demoted, had their work hours or responsibilities reduced, were denied a job because of their history of psychiatric treatment, had a job offer withdrawn, and/or were ostracised and hassled by co-workers.
Their adverse experiences have burdened them with disabling self-doubt and inculcated in them a sense of self-stigmatisation so deep that a great number would avoid applying for a job as they do not expect to be given a fair chance. Nor is this an unjustified pessimism: In surveys over the past five decades, employers have been found to be consistently far more reluctant to hire workers with mental illnesses than almost any other group, including those with a physical disability and former convicts.
Many of these individuals also lack the necessary education and training required for a vocation - often this is due to the early onset of their illnesses: Half of all lifetime cases begin by age 14 and three-quarters by age 24. The disruptive emotional, behavioural and interpersonal difficulties that arise from the illness would derail their schooling, and some fail to get back on track. In our qualification-obsessed society, this impediment in education is a large stumbling block for securing a job with good career prospects.
And then, there is the issue of whether these individuals receive good continuous management of their illnesses. Optimal treatment of serious disabling mental illnesses requires not just medication but also a raft of other psycho-social interventions to improve functioning, including vocational rehabilitation and what is called supported employment.
Research has shown that people with serious mental illnesses can successfully participate in the open labour market through supported employment. This is provided by mental health and rehabilitation professionals working together to do rapid job searches for a patient, placing him or her in a job, and backing that with ongoing support. But the evidence is that many who need these services are not receiving them for various reasons.
DISCLOSURE OF ILLNESS
There is one question that I'm asked every now and then by my patients: Should they disclose their history of mental illness to their employer or manager at their place of work? Or, how should they respond when faced with that pointed question on whether they have any history of mental illness? This question is so ubiquitous in job application forms that it seems to be a norm with most companies, and has made job-seeking an even more suspenseful undertaking for patients. I used to have to suppress that spurt of reflexive response to urge them not to tell the truth, and to counsel that discretion is the better part of valour. But now, I would have a more considered discussion which involves drawing up a balance sheet of pros and cons.
Disclosure might provide an opportunity to ask for some reasonable adjustments such as a more flexible workday, or to explain those symptoms (or the side-effects of medications) that might be affecting their performance in the workplace. Disclosure to colleagues could lead to getting much needed help and emotional support from them. And in no small way, it might also educate others in the workplace about mental health issues.
But there are obvious downsides and risks, one of which is the possibility that disclosure will leak out in one way or another and give rise to mean and mischievous gossip. It could also result in other egregious forms of discrimination. A pusillanimous employer might wait a few months before terminating the services or forcing out the employee on a different pretext , without it seeming like the admission of mental illness was the reason.
There is no law in Singapore for preventing any job discrimination against those with mental illnesses - in contrast to Britain and the US, where there are laws that ban the use of pre-employment questionnaires asking prospective job seekers about their mental health.
The Americans with Disabilities Act (ADA) of 1990, for instance, seeks to protect people with mental health disabilities by prohibiting discrimination in job application procedures, hiring, firing, advancement, compensation, fringe benefits and job training. The ADA allows these individuals to request "reasonable accommodations" to enable them to do their jobs with the caveat that these accommodations must not give their employers "undue hardship" - meaning that they must not be prohibitively expensive, extensive or disruptive, or change the nature or operation of a business. The fact that we have no such law in part comes from the "medical model" that we use to see a person with a disability. From that perspective, such a person is someone who cannot function adequately because of the presence of an organic condition.
In contrast to this "medical model", the "social model" of disability views the disability as an imposed condition that is created by society. Or as summarised by the American writer Andrew Solomon: "If most people are geniuses, those of moderate intelligence would be disastrously disadvantaged." (The more extreme expression of this "social model" is made by the British academic Michael Oliver, who said: "Disability has nothing to do with the body; it is a consequence of social oppression.")
But we can't repudiate the fact that mental illnesses are medical conditions that can result in impairment of functioning - and for which we should ensure that people with such illnesses are given whatever means possible to have access to effective treatments. But neither can we deny that we have also disabled them with various barriers that are created from our prejudices; and in some way, we may have also socially conditioned them to fit our negative stereotypes.
If we take in and accept some aspects of the "social model", it will be an acknowledgement of those unjust societal constraints and signal a willingness to change our prejudicial mental habits. It would also go some way in reducing the stigma that clings so tenaciously to people with mental illnesses and allay their fears of being regarded as disabled and incapable.
If we do want to move towards a more inclusive society, we should not just mouth the usual platitudes about how much we care about people with mental illnesses. Well-intentioned though they may be, such expressions are easy and smack of an ineffectual and insincere kind of sentimentality.
Should we not take the more practical and concrete steps of providing legal protection to prevent discrimination? While we have some laws to support people with disabilities, there is no specific law to penalise discriminatory practices related to disabilities, let alone mental disabilities.
People with mental illnesses deserve a chance to prove that they can work productively. Many with mental illness not only function as well as others, but also often have knowledge, skills, capabilities and experiences that a perspicacious employer would value. The World Health Organisation has estimated that one in four people have a mental illness some time in their lifetime, and it is likely that among our work colleagues, there are some who have mental illnesses unbeknownst to the rest - but who live in fear of that being uncovered one day.
Next Tuesday, Oct 10, is World Mental Health Day and the theme this year is "Mental Health in the Workplace". If anything, it is to remind us again that we still have quite a way to go in making the workplace a stigma-free environment for those with mental illnesses, where they will be treated with decency, compassion and fairness, and where there is no fear and no need for denial and subterfuge.
The writer is vice-chairman of the medical board (research) at the Institute of Mental Health.
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