Madness and Work: Short- and Long-Term Effects of Mental Illness on Occupational Careers

Madness and Work: Short- and Long-Term Effects of Mental Illness on Occupational CareersAuthor(s): Carol L. Huffine and John A. ClausenSource: Social Forces, Vol. 57, No. 4 (Jun., 1979), pp. 1049-1062Published by: Oxford University PressStable URL: http://www.jstor.org/stable/2577258 .

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Madness and Work: Short- and Long-Term Effects of Mental Illness on Occupational Careers*

C AR O L L. H U FFI NE, University of California, Berkeley JOHN A. CL AU SEN, University of California, Berkeley

ABSTRACT This study assesses the impact of mental illness on occupational careers.

Thirty-six married men who first entered mental hospitals in the 1950s were followed up in 1972 and eighteen men who were first hospitalized in 1973 -74 were interviewed. Their histories reveal the importance of the development of competence in the work role prior to the onset of mental illness. Those who were able to develop competence were likely to retain their jobs through the initial episode of illness and to remain occupationally stable in the ensuing years even in the face of persistent symptomatology. The data are interpreted as evidence that the label, "mental patient," does not constitute a master status and in and of itself does not significantly affect occupational careers.

In a society such as the American, one's work role-particularly if one is male-is the sine qua non of status as a mature and competent member of the social order. The ability to work becomes an essential component of self-esteem and is viewed as evidence of mental health. It is, in fact, often used by therapists, family, and patients themselves, as proof of recupera- tion from mental illness. This is so in spite of the fact that for many men the work role is the least affected by mental illness. Its resiliency to the destruc- tive effects of mental illness has been noted by researchers and clinicians alike (Olshansky et al.; Simmons).

There is a substantial literature on attitudes toward former mental patients as workers and on the occupational experience of former patients following hospitalization. But there have been few studies of the long-term employment histories of former patients. In this paper we shall briefly review the evidence from previous studies and then examine data from a fifteen- to twenty-year follow-up of male patients who were confined in a

*The research here reported has been supported from 1971 to date by Grant MH-19649 from the National Institute of Mental Health through the Institute of Human Development, Uni- versity of California and by additional funding from The Grant Foundation in 1975-78. The assistance of Nancy Pfeffer and Bruce Turetsky is gratefully acknowledged.

C) 1979, University of North Carolina Press. 0037-7732/79/5704/7361$01.40

1049



1050 / Social Forces / vol. 57:4, june 1979

public mental hospital for the first time during the 1950s. Our data will permit us to examine the implications, for a man's occupational career, of having been an inmate in a public mental hospital.

Acceptance of the Patient as Worker

A former patient's performance in the work role may be limited either by resistance to employing him or impairment of his ability to work. Labeling (or societal reaction) theorists would predict that an irrevocable change in social identity, caused by being defined as mentally ill, substantially limits all of one's future opportunities, including the occupational. It is argued that the deviant label acts as a master status which, overriding other statuses an individual may possess, determines how others will respond to him (Becker; Scheff, a, b).

Gove, who has been an articulate critic of the utility of societal reaction theory in the area of mental illness, has pointed out that though the public holds a highly negative stereotype of the mentally ill, there is little evidence of actual discrimination (Gove and Fain). It may be that the intensity of the negative stereotype actually deters its application. That is, the stereotype is generally inconsistent with the way the mentally ill be- have on a day-to-day basis. The general principles of cognitive consistency theories would predict that the more access we have to an individual's behavior, the more inconsistent with our cognitive set toward him will be the label "mental patient" and the less that label will influence our interaction with him.

Accumulated evidence about the employability of mental patients is consistent with this latter hypothesis. Acceptance of the former mental patient into the work-place appears to be directly related to the amount of information the gatekeeper possesses that offsets the negative connotation of the status, mental patient. Thus, survey respondents who are asked to agree or disagree with the statement, "I would rather not hire a person who has been in a mental hospital," express high levels of rejection (Whatley). Given no more information than this, a respondent is likely to operate on the basis of a stereotype of the mentally ill which may well include im- pulsive violence, inability to tolerate pressure and inability to interact harmoniously with co-workers (Olshansky).

Less rejection is seen when respondents-whether in an experi- mental or real life situation-are asked to make decisions about employing former mental patients they have interviewed (Farina et al.; Olshansky et al.; Rennie et al.). Here, the prospective employer is able to use information about the individual's appearance, interactive skills, and work history to test the applicability of the stereotype of the mentally ill.

Finally, employers are very likely to accept back to work their own



Madness & Work / 1051

employees who have experienced mental illness (Brown et al.; Olshansky; Rennie et al.). Here, the employer or a surrogate knows the former patient as a person and the attribute "mental illness" is likely to be inconsistent with personal knowledge. Moreover, workers who have been on the job for many years are apparently more likely to retain their jobs in spite of psychiatric hospitalization than are people who held their jobs for brief periods prior to admission (Brown et al.).

Capacity to Work

Follow-up studies of former mental patients reveal characteristics associated with employment status subsequent to a mental hospitalization. For instance, severity and chronicity of the illness are important factors. Rapid onset of illness and being found free from illness at the time of discharge from the hospital are associated with working steadily following release (Schooler et al.). The number of times a person has been hospitalized for mental illness and the length of the index hospitalization (that hospitalization which resulted in the patient becoming a research subject) are inversely related to the probability of working and being occupationally stable after release (Brown et al.; Freeman and Simmons; Keith et al.; Olshansky et al.; Strauss and Carpenter).

Perhaps the most powerful predictor of post-hospitalization work pattern is the pre-hospitalization occupational history. If a patient has, in the past, worked effectively and stably, the probability is high that he will do so again. If he has not displayed the ability to perform effectively in the work role prior to mental illness, there is very little likelihood that he will be effective after treatment (Brown et al.; Olshansky et al.; Simmons; Strauss and Carpenter).

Studies of post-hospitalization occupational histories suggest, then, that ability to perform in the work role may be more important than any stigmatizing effect of mental disorder in influencing the subsequent career of the former mental patient. Yet many labeling theorists still argue that once a person has acquired the status of mental patient, subsequent career opportunities will be altered irrespective of subsequent health status or instrumental competence. The question is not whether stigmatization of mental disorder still exists; few would argue that it does not. Rather, we address the question: "How have the long-term careers of married men who have undergone hospitalization for severe mental disorder in a public facility been influenced by that initial hospitalization and its sequelae?"

Although our sample is small, it is strategic. Married males are not typical of all male patients; the ability to form a relationship with the opposite sex is indicative of positive prognosis, especially for male schizo- phrenics. Also, married patients are likely to experience their initial break-




down at an older age than unmarried patients and are, therefore, more likely to have had some sort of occupational career. But the stigmatizing aspect of confinement to a mental hospital should be no less for a married man than for a single one. Therefore, a sample of married, first admission patients with a severe disorder (most frequently schizophrenia), followed up fifteen to twenty years after initial hospitalization, should be a strategic group for the examination of occupational careers. As we shall see, some of the men suffered recurrent symptoms and rehospitalization; others did not. We can see what difference this made.

The Sample

Between 1952 and 1959, a study of the impact of mental illness on the family was undertaken by the staff of the Laboratory of Socioenvironmental Studies at the National Institute of Mental Health. The families selected for the study were those of married, white persons between the ages of 20 and 49 years who had entered a Washington, D.C., area mental hospital as first admission patients with diagnoses of functional psychosis, affective disorder or severe psychoneurosis or character disorder. Actual inclusion in the sample depended on availability of an interviewer at the time of the patient's admission and willingness of the patient's spouse to be interviewed. Fewer than 10 percent of the wives of male patients refused to participate in the study. Thus, this should be a reasonably representative sample of married male patients experiencing an initial hospitalization.

The patients described in this paper are the 36 men among a total of 80 patients who met all the study criteria. Basic descriptive information is presented in Table 1. Most of the men were under the age of 40 years at the time of their hospitalization and over half were diagnosed schizophrenic. Fuller descriptions of the study are provided in Clausen; Clausen and Yarrow.

The Data

The initial group of respondents (19) were interviewed intensively and frequently. The staff used general research questions as a framework for an average of 11 interviews which were open and otherwise unstructured. To secure more systematic data at lower cost, subsequent interviewing became more structured: a questionnaire was developed and the number of interviews sought was reduced to four-three conducted during the hospitalization, and the fourth, ideally, six months after release. For analy- sis, the material obtained in the early phase of the study was subsequently abstracted and coded to make it consistent with the data collected in the later stages.



Madness & Work I 1053

Table 1. CHARACTERISTICS OF PATIENTS AT TIME OF INDEX HOSPITALIZATION

Tota 1 36

D i agnos i s

Schizophrenia 20 Affective psychosis 9 Psychoneurotic/character disorder 7

Age

20-29 years 11 30-39 years 15 40-49 years 10

Occupational Status

Administrative, managerial, professional 9 Technical, sales, clerical 16 Skilled manual 5 Semiskilled or unskilled manual, operative 6

Early in the interviewing sequence, occupational histories of the patient and his wife were obtained and questions about effects of the illness and hospitalization on the patient's job were asked. Following the patient's release, attempts were made to gather data on his re-entry into the world of work.

In 1972, a follow-up study was commenced. Except as noted below, efforts were made to interview all the spouses whether they had partici- pated throughout the original series or had terminated prematurely. For 26 of the 36 men in the sample, the primary source of follow-up information was the wife and in most instances the data were collected in an interview requiring an hour and a half to two hours to complete. Three former patients were, themselves, primary informants because the marriage had been terminated and the wife could not be located. No attempts were made to reach three wives whose husbands had died in the course of the original interviewing or prior to a limited follow-up five years after admission. In the remaining four cases, clinical records and/or relatives other than spouses served as primary sources of information. (Wives were un- available or unwilling to participate and the patients were dead or family members asked us not to attempt patient interviews.)

The follow-up interview focused on the long-range impact of the illness and hospitalization. Data were obtained on the work experiences of the former patients and of their wives subsequent to the index hospitalization. Systematic interviewing of patients as well as of spouses provided us with data and perspectives which, in the earlier study, were sometimes not available. Where appropriate, we will draw upon the data from the 18 men in the new cohort to fill in the picture or to reveal important differences in the experiences of the two generations.




Findings

PRE-HOSPITAL CAREERS

All the men admitted in the 1950s were working at the time their illnesses became apparent or they were convalescing from physical trauma that had interrupted their work lives. Most were white collar workers (Table 1). Half had been with their current employers five years or more at the time of their admission to the psychiatric hospital. Of the other half, most had recently completed schooling or military service or they worked in oc- cupations characterized by frequent shifts in employer (e.g., real estate salesman). Only four men appear occupationally unstable at the time of hospitalization. Three had been more stable as younger men but in the years immediately preceding admission they worked shorter and shorter periods at their jobs. The fourth man was chronically unstable, occupationally.

Two men had not worked for six months or more prior to their admissions because they were recuperating from serious trauma-a heart attack and an automobile accident. Of the other 34, over 40 percent worked to within one week of admission and almost 80 percent worked to within one month of admission. For a great many of these men, stopping work came long after they had ceased functioning effectively in other major roles, among them the marital role. This does not mean, however, that they were symptom-free at work. In fact, most of them had some problems on their jobs in the pre-hospitalization period. For a few, the problems were confined to the week just prior to hospitalization but almost one- third of the men had manifested problems such as excessive absenteeism and interpersonal conflict with co-workers for six months or more before hospitalization.

It was not common for colleagues to define a man as mentally ill during the pre-hospitalization period, but the behavior of some of the men became sufficiently deviant that co-workers or supervisors commented on it. In a few instances co-workers were directly involved in the process of hospitalizing a patient. These patients revealed even more symptoms at home than at work but their wives tended to be quite passive about the deviance or to be naive about its implications. For instance, after some fruitless attempts to get her husband to explain his unusual behavior, Mrs. Ashly dismissed it. "I was getting kind of used to it by then. He's always been so quiet and all, and I never paid too much attention to it." When Mr. Ashley's supervisor was confronted with an alternately loquacious and unresponsive, mute employee, however, he initiated the process which resulted in Mr. Ashley's hospitalization.




RETENTION OF THE JOB

Shortly after their husbands' admissions, the wives were asked whether the patient's former job would be available upon his release from the hospital. Nineteen said they were certain their husbands' jobs would be available. One woman terminated participation in the study before this question could be put to her. Half of the remaining 16 wives did not know the status of their husbands' jobs or felt that they might be available under some circumstances e.g., ability to pass security clearance investigations. The jobs of the other eight men were reported to be definitely not available. For half of this latter group, the job loss was a direct and clear concomitant of the mental illness. They were either fired when their symptoms inter- fered with their own functioning and with the smooth operation of busi- ness, or they quit the job as a consequence of emotional upset. Two other dismissals may have been indirectly related to the mental illness, while the final two were probably incidental to it.

Having the job available was associated with the man's age, work status, and occupational stability as well as with some facets of the illness itself. As a group, the men whose jobs remained available to them through the period of hospitalization were older at the time of admission than were the men whose jobs were not available (Table 2). Men who occupied higher status jobs (administrative, management, or professional level) were somewhat more likely than lower level workers to retain their jobs. Among the lower level workers, most of those who had been with their employers for more than five years were assured of having a job to go back to while few men who had not been employed so long retained their jobs (Table 3).

That characteristic of the illness which most strongly relates to the availability of the job is the duration of pre-admission symptoms (Table 4). This period, determined by the spouse's response to a question asking when she first noticed something different about her husband's behavior, is commonly used as a prognostic indicator in schizophrenia. Of the men in this sample who had been symptomatic for six months or longer, only

Table 2. AVAILABILITY OF JOB AT RELEASE FROM HOSPITAL BY AGE AT TIME OF ADMISSION

Avai lable Age at Admission Yes No

Less than 33 years* 4 11

33 or more 15 6

2 X = 5.35, p <.05

*33 years was the median age of the 36 men at time of admission.



1056 I Social Forces I vol. 57:4, june 1979

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Table 4. AVAILABILITY OF JOB AT RELEASE BY DURATION OF SYMPTOMS IN THE PRE-HOSPITALIZATION PERIOD*

Duration of Symptoms Prior to Admission

Less than 6 Months More than 6 Months

Job available 14 4

Job not available 4 11

X2= 6.57, p<.02

*Excluded are two men who, because of physical illness, stopped working prior to onset of mental illness and one man whose wife terminated participation prior to being asked about the availability of her husband's job.

31 percent had their jobs available to them upon release while 75 percent of the men who had been symptomatic fewer than six months retained their jobs. There is, however, no relationship between the manifestation of symptomatology on the job and retention of the job. Nor, when duration of pre-admission symptomatology is held constant, is work role impairment associated with loss of the job.

THE RETURN TO WORK

Two of the 36 men in the original patient cohort killed themselves during the index admission. Of the remaining 34, 70 percent were hospitalized for three months or longer. Upon release, 17 returned to their old jobs, nine within one week of leaving the hospital and five more-over 80 percent in all-within one month of release.

In the cohort of patients studied more recently, all but two of the 18 men returned to their previous jobs. This cohort difference may be due to treatment practices as well as to differences between the groups of men themselves. In the 1970s, patients were hospitalized a few weeks rather than several months. The cohorts differ in age; the men admitted in recent years were older, as a group, than the men initially hospitalized in the 1950s. There is also an apparent difference in the amount of work role impairment. Only three of the 18 men in the more recent cohort but almost half the men in the original cohort were described by their wives as im- paired in their work roles from the onset of symptoms.

As the men returned to work they and their wives tended to be sensitive to evidence of stigmatization. However, there were few instances in which the former patients were able to report direct experience of it. Indeed, most men either perceived no change in their relationships with co-workers or found their colleagues sympathetic or conciliatory. The lat-




ter, however, made some of the former patients uncomfortable. In neither cohort did more than a couple of men experience overt hostility from co-workers. Apprehension and lack of confidence were common in the early days of return to work, but ability to perform in the job dispelled self-doubts.

FINDING A NEW JOB

As one would expect, those men who in the 1950s did not retain their jobs took longer in returning to work than did the men whose jobs were available to them. Contact was more often broken where the men lost their jobs (some left the study area) so we do not know, in a little over one-third of these cases, just when the man returned to work though we know whether he returned. Where the data are available, less than half the men were back at work within a month of their release. Though some of the former patients had considerable trouble getting new jobs, it was uncommon for the difficulty to be attributed to the hospitalization.

Follow-up

Twenty-nine of the original 36 men survived to 1972-73. Focusing now on them, we will address the questions posed earlier. What are the career experiences of men who, in spite of lengthy hospitalization in public mental hospitals, experience no recurrence of symptoms in subsequent decades? Similarly, what are the experiences of men who have continued to experience symptoms-mild or severe?

Nine men had, from all accounts, been symptom-free for at least five years prior to the follow-up and most of them had experienced no recurrence of symptoms since the index hospitalization. At the time of follow-up all were working at jobs of equal or higher status than those in which they worked prior to admission (Table 5).

Since their initial episode of illness, nine other men have been reportedly mildly symptomatic or they have experienced infrequent re- currences of serious symptoms. Five of them continue to work at levels equivalent to or higher than prior to the index hospitalization while four have slipped to lower occupational levels than previously occupied.

The remaining nine men for whom we have sufficient data to assess the course of illness have been persistently and seriously symptomatic in the years following the index hospitalization. Only one has not been rehospitalized-the others have had an average of four readmissions. In spite of this, four of the nine have continued to work at levels at least equal to those at which they worked before their initial episodes of illness. Only one of the four is a blue collar worker. Another-a salesman-has had to




Table 5. OCCUPATIONAL STATUS AT FOLLOW-UP BY SEVERITY OF SYMPTOMS IN THE PRECEDING FIVE YEARS

Occupational Status Occupational Status at Follow-Up Higher at Follow-up Lower

Symptoms in 5 Years than Prior to than Prior to Prior to Fol low-up Admission or No Change Admission

None 9

Mi ld or infrequent 5 4

Persistent and serious 4 5

Insufficient data to classify 1 1

find new jobs after most of his numerous hospitalizations but in the year preceding the follow-up, he was-according to his wife-"top man in the company" for which he now works. The other two men hold good jobs requiring high levels of skill. The ability of these four men to continue to work effectively and to retain their jobs in spite of recurrent or persistent severe symptomatology is impressive indeed.

Although some of the men who have been downwardly mobile were, in the period preceding the index hospitalization, beginning to mani- fest some evidence of occupational instability, all were employed and half were white collar or skilled workers. By the time of the follow-up interview, most had, for many years, been unable to function at all effectively in a work role.

Wives described a variety of effects they thought their husbands' illnesses and hospitalizations had exerted on their careers. Only two, however, reported feeling that the hospitalization, in and of itself, had created problems. One thought her husband might have been promoted further and faster had it not been for the hospitalization and another felt that her husband had been barred from federal employment because of his history of mental illness.

Thus, even chronic illness is not assurance of downward career mobility. Degree and persistence of symptoms are clearly related to occupational impairment, but pre-hospitalization occupational experience is an even more potent predictor. Even among those who have had subsequent episodes of illness, long-term employment and short-term symptoms prior to hospitalization and resumption of the former job upon release are associated with stable or upwardly mobile careers. The occupationally stable men were also somewhat older at the time of the index admission than were the downwardly mobile (Table 6).




Table 6. FACTORS ASSOCIATED WITH OCCUPATIONAL STATUS DIFFERENCES AMONG MEN WITH PERSISTENT PSYCHIATRIC SYMPTOMS

Occupational Status at Follow-up

Higher than or Equal to Lower than

Pre-admission Pre-admission

Length of Time on Job PTA*

More than 5 years 6 2 Five years or less 3 7

Duration of Symptoms PTAt

Less than 6 months 8 3 Six months or more 1 6

Job Status After Release from Index Admission4

With previous employer 8 1 Not with previous employer 1 7 Not working 6 months PTA - 1

Age at Time of Index Admission*

33 years or over 7 3 Less than 33 years 2 6

*n. s.

tp <.025 (Fisher Test)

tp <.01 (Fisher Test)

Discussion

These data provide strong evidence that, in and of itself, being labeled mentally ill does not determine the course of a man's career even though he may be confined for months in a public mental hospital. Those men whose symptoms abated-either at the end of the initial episode or within a few years thereafter-have not suffered gross occupational setbacks. Even continued symptoms of significant proportions are not assurance of downward drift. The career of a man who was able to establish his competence prior to the initial onset of illness stands a good chance of surviving the ravages of prolonged, even severe, symptoms. Thus, the label "mental patient" did not serve as a master status. We suggest that this is because the stereotype that the label represents is markedly inconsistent with the behavior these men engaged in most of the time and with other dimen- sions of their personalities which were more relevant for role partners.

We suggest, also, that use of the concept "master status" is ques-




tionable in this and other instances of deviance. Attempting to explain the dilemmas and contradictions of status, Hughes hypothesized that a master status-determining trait can "overpower, in most crucial situations, any other characteristics which might run counter to it." The two traits that Hughes described as master status-determining ones are race and sex. These are traits we respond to in patterned ways learned through long years of socialization and experience. This is not the case with mental illness. Few are schooled in what to expect from mental patients and how to interact with them. Psychiatrists, psychologists, social workers, mental health researchers-these are people who have learned a pattern of interaction with the mental patient. It is to just such people that "mental patient" may serve as a master status.

A substantial proportion of the men reported upon here have, however, met with nothing but failure in their attempts to function occupationally since their hospitalization as mental patients. Their short pre- admission job tenures suggest that, compared to the occupationally stable men, they were less well established occupationally. There is evidence also that their initial prognoses were not as good as the men who have been occupationally stable. The downwardly mobile men were younger at the onset of their initial episode of illness and they were symptomatic for longer periods before entering the hospital. Further, their symptoms are more likely to have persisted to recent years.

We emphasize again that the sample reported on here is an un- selected group of married, male, first-admission patients. As such, they do not represent male mental patients and are, as earlier noted, relatively advantaged. This sample is, however, reasonably representative of first admission married males with functional diagnoses and we would stress the importance, in studying the impact of mental illness or the effects of hospitalization, of starting with patients on their first admissions. The typical sample of mental patients is disproportionately composed of readmissions.

Though the findings of this study cannot be generalized to all mental patients, the details elicited from this small group of men clarify the com- plex relationship between mental illness and occupational careers. Being labeled mentally ill does not appear to markedly affect a man's career. The persistence and severity of the illness are important factors but not neces- sarily decisive. Also important is how successfully the individual has previously been socialized into the work role. The data presented here and elsewhere show that successful socialization and the development of competence are likely to result in a resilient work role and an individual less likely to have to sacrifice his career to mental illness. There are aspects of the social environment such as the character and structure of the work- place which may facilitate or impede reestablishment of his career after an episode of illness. The present sample is too small to address this question




but such important areas remain relatively unexplored and are uniquely amenable to the analytic skills and techniques of the social scientist.

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Madness and Work: Short- and Long-Term Effects of Mental Illness on Occupational Careers