Long-Term Unemployment: A Social Determinant Underaddressed Within Community Behavioral Health Programs

Gainful employment is a social determinant with the potential to contribute to positive emotional and general health for people with serious mental illnesses. However, lack of gainful employment for this population has not been equally recognized for its negative clinical effects. In this column, we examine how unemployment is detrimental to overall wellness, a notion that is now widely accepted in social psychology and related fields. Although supported by a multitude of epidemiological correlative research, this information is largely overlooked in the mental health field.

Links Between Employment and Health

Substantial evidence shows an association between long-term unemployment and poor general and mental health outcomes, even in the absence of preexisting conditions. Although it has seemed intuitive that having a major mental illness interferes with employability, much literature indicates that long-term unemployment plausibly exacerbates, or perhaps even initiates, symptoms. Furthermore, there are at least enough strong correlational, if not provably causative, data from studies to credibly infer that long-term unemployment has the potential to be deleterious to one’s general and mental health even without the presence of preexisting deleterious health conditions.

In addition, experiences such as perceived job insecurity, downsizing or workplace closure, and underemployment also have implications for general and mental health. The concept of work disincentives (e.g., “benefits cliff,” concern over loss of related resources such as Medicaid or Section 8 housing vouchers) related to working when a person receives SSI or SSDI support has been well documented elsewhere. The intent of this column is to add to the understanding of the copious risks associated with not moving toward employment.

Such data exist from 1938 (1) through the present day (2), with numerous epidemiological studies in the intervening years (3, 4). Therefore, long-term unemployment can be conceptualized as a significant risk factor that mental health authorities have an ethical and clinical responsibility to address. Evidence supports the conclusion that work can be good for one’s overall health, such as the findings of a 2012 systematic review (5) that revealed a beneficial effect of returning to work on health, either demonstrating significant improvement in health after reemployment or significant decline in health attributed to continued unemployment. The authors of that study concluded that return-to-work programs may improve not only financial situations but also health.

Employment status is commonly recognized as a key social determinant within mental health systems of care, with some attention paid to the potential benefits of working. However, much less attention has been focused on the deleterious effects of long-term unemployment. As far back as 1938, Eisenberg and Lazarsfeld (1) determined that unemployment tended to make people more emotionally unstable than they were previous to unemployment. Warr and Banks (4) found a strong positive association between unemployment and increased substance abuse, increased physical problems, increased mental disorders, reduced self-esteem, loss of social contacts, and alienation and apathy.

Jin and colleagues (6) identified a strong positive association between unemployment and poor overall health. Darity (7) found that periods of unemployment led to lower self-esteem and lower motivation. Lee and colleagues (8) stated that unemployment may be an important risk factor for alcohol use disorder and nicotine dependence symptoms. Stam and colleagues (9) postulated that the drop in income during unemployment is detrimental to well-being because it restricts unemployed individuals in planning their future and is “psychologically corrosive”; moreover, they suggested that the lack of other nonpecuniary elements associated with employment (e.g., time structure, shared experiences and contacts outside the nuclear family, shared goals, personal status and identity, and enforced activity) leads to lower well-being.

Druss (10) suggested that the mounting evidence of positive employment outcomes when using evidence-based supported employment challenges state authorities to consider the importance of recognizing employment services for effective treatment for individuals with serious mental illnesses. Nonetheless, although an increasing number of programs across the United States have implemented excellent, evidence-based supported employment with success, the overall impact on state and county systems of care for people with psychiatric disabilities has been negligible in terms of employment outcomes reported through the Substance Abuse and Mental Health Services Administration data portal. In many regions, evidence-based employment services are not available. This deficiency may be due to lack of awareness of how this social determinant is equally as important as treatment access. Through policy, research, and service-funding, many have sought to answer the question, “If people choose to work, what is the most effective intervention to accommodate this need?” However, perhaps a more useful question would be, “Because unemployment is so harmful, how can we help more people overcome this barrier and reduce their general health risks?”

Lack of Significant Attention Paid to Long-Term Unemployment

At first glance, the distinction between these questions may seem negligible. However, creating a focus on successful employment for motivated individuals is significantly different from assertively intervening to change a trajectory of unemployment for a defined population group. Highlighting long-term unemployment as a clinical risk factor for mental illnesses and other health conditions requires an assertive, medically necessary response by all direct service staff, even those not directly involved with employment service delivery. This response should be deployed proactively for people who have, or are at risk of having, long-term unemployment, not just when there is a stated desire from someone interested in pursuing employment now.

Although it is a common refrain to note the high percentages of people with mental illnesses who state the desire to work, anecdotal evidence from numerous field reports has indicated that this genuine desire is not often expressed as a firm request, meaning that the mental health clinician or case manager neglects to make a referral to an employment service even though the person is interested. It is not that people who want to be involved in employment intervention are denied the opportunity to do so but rather that service providers do not perceive the clinical implications of the person’s situation as a long-term unemployed individual; therefore, service providers adopt a passive approach unless a person specifically and assertively requests job placement help.

Many states have endorsed the “Employment First” paradigm, which led to enacting policies and programs to support the employment of people with disabilities. However, no policy mandate explicitly identifies employment as an expected outcome of the state mental health system of care. As a result, most state mental health policies neither incentivize employment as an outcome nor sanction service delivery intermediaries within the system that do not affect the employment status of large numbers of their clients, which we see as equal in importance to other clinical goals such as medication management and treatment.

Given the overwhelming consensus about the role of unemployment as a social determinant and key driver of declines in general and mental health, this administrative lapse looms especially large. The result is that employment is seen as a social or economic problem rather than as a concomitant serious health risk. Employment advocates cite paid work as providing a job role identity, an avenue out of poverty, and an increased social network. These benefits, although true, may not seem urgent to service providers, policy makers, or funders. Reframing long-term unemployment as a health risk not only elevates it as a critical issue for the well-being of people served by the system but also points to the major costs of not preventing and addressing its many negative consequences.

Caveats

Two caveats should be kept in mind, even as some mental health service delivery systems begin to recognize the deleterious health effects of long-term unemployment. In simple terms, the negative effects on one’s physical and mental well-being of being unemployed over a long period likely outweigh the positive value of any one job for any one individual. Certainly, specific job conditions can be stressful in ways that contribute to physical morbidity, but this challenge can be effectively addressed by intermediaries who assist people with psychiatric disorders to access jobs that reflect their skills and values and support them in ways that maximize their success.

The second caveat is recognizing that addressing long-term unemployment is not synonymous with mandating work as a requirement for receipt of health care benefits or food support. Enhancing resources to assist an individual’s vocational achievement can ameliorate the negative impact of this social determinant, whereas the withdrawal of other social supports will increase the negative impact of other social determinants, an approach that appears self-defeating at best.

Recommendations

Simply recognizing that mental health care service delivery systems do not adequately address the extreme health risks attendant to long-term unemployment of most adult clients does not point directly to possible solutions. Some feasible low-cost strategies and interventions that can be implemented within these systems include addressing how providers deliver services to all the people they serve, reinforcing mental health providers’ commitment to viewing long-term unemployment as a health risk.

An initiative implemented by one of the authors in his role as an associate executive director of a large community mental health center required all clinical staff to address long-term unemployment on service plans. This policy is similar to the way many agencies require mandatory crisis planning for service plans, even if not specifically requested. This initiative did not mean forcing anyone to seek employment when they did not wish to do so. Rather, it required clinical staff to engage individuals served in understanding the potential positive and negative health effects of their continued unemployment, identifying the internal and external barriers they faced in rectifying this situation and developing interventions to help them overcome these vocational impediments. Some external issues that impede a person’s employment success include discrimination, lack of flexibility or leave to address health issues, and policies that limit employment for people with a criminal record.

The data on evidence-based supported employment have contributed substantially to the creation of many such programs throughout the United States and the world. However, to some extent, this progress has provided a false sense of accomplishment because comparatively few people actually have access to these evidence-based employment programs. Although there has been an increase in supported employment programs nationally, the broader view of employment as a systemwide health improvement goal has not taken root. Further research is needed to better understand the beneficial effects of employment on health and to promote interventions that address disparities in employment and health. This additional evidence will facilitate public health efforts to address employment by reframing it as a social determinant of health.

Attacking unemployment more aggressively will demand activities beyond the aforementioned service plan redesign. In particular, public systems of care, whether state, regional, or county, must undertake activities to enhance efforts between mental health systems of care and strictly employment-focused systems (vocational rehabilitation, Workforce), including joint funding agreements and information protocols that allow for regular updates on mutual clients. Additionally, state and regional policy and funding authorities should ensure that all community mental health care programs include as one of their performance metrics either a specific goal of enhancing employment outcomes (e.g., job acquisition, job search attempts, job interviews obtained) for people served or, at a minimum, provide regular reporting on the employment status of all adult clients, regardless of whether they are receiving specific employment-related services. Transparency and effective dissemination strategies also play a role in countering the negative social consequences associated with long-term unemployment. Thus, reporting publicly available information on employment status and employment goals achieved for all the adult clients they serve on a quarterly basis would reinforce this goal.

The other key players needed to make a positive impact within the employment sector of the social determinant framework are the direct mental health service organizations (e.g., community mental health systems, coordinated care organizations, accountable communities of care). An initial administrative step that can and should be taken is requiring all clinical staff to assess unemployed people served in terms of what specific employment strategies might be most beneficial and targeted to their unique needs, even if the person does not explicitly request assistance in employment. This requirement creates a service expectation for gathering baseline data on the employment situation of all clients and subsequently setting improvement goals on the basis of this baseline.

In addition to making administrative adjustments in service delivery, or even in the absence of funding or administrative mandates, practitioners can deliver clinical interventions using well-established motivational interviewing techniques. Mental health clinicians, case managers, peer providers, and other direct support staff can be trained and prompted to ask on every visit about the client’s interest in working or what the person has been doing to make efforts to get a job, keep a current job, or find a more fulfilling job. Clinical and other community mental health service personnel can be expected to advise clients about the negative effects of remaining in poverty for the entirety of one’s life, much as they might for other health risks, emphasizing how remaining under- or unemployed is one significant barrier that contribute to lifelong poverty and consequent health risks. This advice must be delivered with an understanding that there are multiple causes of poverty and poor health that may lie outside the client’s capacity to totally control. This inquiry would be followed by assisting the client to move closer to employment, whether focused on vocational counseling, vocational choice, career decision making, job search, informational interviews, supported employment referral, or intercession with a specific employer.

Practitioners, administrators, funders, and policy makers need to recognize the magnitude of unemployment in contributing to major health and quality-of-life disparities. Appreciating the urgency of addressing this key social determinant is a prerequisite to investing in the actions needed to undo the damage incurred by long-term unemployment.