Work assets and drains: Employment experiences of women with serious mental illness

Abstract

BACKGROUND:

While considerable research has been conducted on employment of people with serious mental illness (SMI), there is a dearth of research in this area focused on the work experiences of women with SMI.

OBJECTIVE:

This article fills a gap in the research by presenting the results from a study exploring the work experiences of women with SMI.

METHODS:

Grounded theory methodology was used to analyze the qualitative data. Several qualitative validity strategies were employed to enhance data quality.

RESULTS:

Six themes relating to work emerged from analysis of the qualitative data: (1) work drain; (2) symptom visibility; (3) work disclosure; (4) inconsistent work; (5) nontraditional work; and (6) work assets.

CONCLUSIONS:

Vocational rehabilitation practitioners can tailor rehabilitation plans to support the unique needs of women with SMI and leverage their strengths to help them gain greater satisfaction and meaning from work.

Keywords

Women serious mental illness SMI work employment

1 Introduction

According to Substance Abuse and Mental Health Services Administration (SAMHSA) statistics, 4.2% of American adults experience from a serious mental illness (SMI) in 2016 (Ahrnsbrak, Bose, Hedden, Lipari, & Park-Lee, 2017). SAMHSA defined SMI as “any mental, behavioral, or emotional disorder that substantially interfered with or limited one or more major life activities” (p. 3). Employment can play a key role in recovery from serious mental illness (SMI). Along with greater financial resources, work can provide people with SMI with structure, relationships, self-esteem, and opportunities for personal development (Dunn, Wewiorski, & Rogers, 2008; Millner, et al., 2015).

However, much of the extant literature presents men and women with SMI as a single group and focuses on the outcome of programs designed to help them obtain and retain a foothold in the world of work. Few if any publications to date specifically discuss the employment experiences of women with SMI. This study addresses this gap in the literature by presenting qualitative results from a grounded theory study involving 20 women with SMI. In this article, we will discuss several work-related themes that emerged in the experience of these women, along with associated clinical implications.

1.1 The desire to work

Research suggests that many people with SMI have a strong desire to work. Participants with symptoms of psychosis who were interviewed by Dunn et al. (2008) described their personal work histories and strong work ethic with pride, characterizing themselves as hard workers who were eager to rejoin the workforce. Other participants indicated that work helped them cope with their illness, enabled them to grow emotionally, and provided them with a higher quality of life. Some stated that they had worked even during periods of acute mental health episodes and homelessness. One participant indicated that at one point, work was the “only thing in my life that had any value” (p. 61).

In a related study by Millner and colleagues (2015), adults with SMI were surveyed about their experiences with work. Themes emerged with regard to factors relating to vocational self-efficacy, including personal accomplishments (associated with work), vicarious learning (or positive models of work), social persuasion (i.e., supports), and physical or emotional states (such as motivation or symptoms). In addition, key experiences with work included outcome expectations (loss, benefits, challenges), personal goals, and contextual barriers (e.g., illness and health). Participants tended to express a strong desire to return to work even after periods of homelessness and hospitalization, along with feelings of accomplishment in being able to hold a job.

Not only do individuals with SMI express a desire to work, but they commonly seek out state and federal vocational rehabilitation services (Rosenthal, Dalton, & Gervey, 2007). However, vocational outcomes for individuals with psychiatric disabilities are generally much poorer than outcomes for individuals with physical disabilities. A lack of mental health support on the job may account for part of this disparity. Individual placement programs that incorporate mental health treatment have successfully enabled individuals with SMI to find and keep competitive jobs in their communities (Corbière, Bond, & Goldner, 2005; Marshal et al., 2014). However, in order to tailor vocational rehabilitation services across genders, more information is needed about how women with SMI experience work.

1.2 Barriers to work

The road to employment is not an easy one for people with SMI. According to Arbesman and Logsdon (2011), citing statistics from 2003, people with any kind of psychiatric disability had an employment rate of 48%, which was much lower than the rate for people with other types of disabilities (75%). People with SMI had an employment rate of 37%, which was 11% lower than the rate for people with psychiatric disabilities overall. According to 2015 statistics, 52.2% of people with SMI who lived in households were employed in 2015 (ODPHP, n.d.). The 2015 employment figures for people with SMI receiving public mental health services were lower: 45.4% or 21.7%, depending on whether the overall sample was people with SMI considered to be in the labor force (i.e., employed or unemployed), or the overall sample was people with SMI who were employed, unemployed, or not in the labor force (SAMHSA, 2015).

Some of the factors that hinder success in the workplace for people with SMI appear to include stigmatization, discrimination, poor social skills, cognitive deficits, and positive symptoms, such as auditory hallucinations (Saavedra et al., 2016). People with SMI may be challenged in forming relationships with coworkers due to stigmatization and community rejection. This can contribute to low self-esteem and social withdrawal on the part of those with SMI, who develop an expectation that they will be negatively evaluated in various settings, such as at work (Rubin, Menon, & Vanek, 2012).

Motivation is cited by some researchers as a key impediment for people with SMI, despite research indicating that many people with SMI have a desire to work. Some hypotheses for this are discouragement due to frequent barriers, negative symptoms characteristic of some SMIs (e.g., schizophrenia), fear of losing disability income, and fear of encountering negative reactions from coworkers and supervisors (Saavedra et al., 2016). Another factor mentioned as a demotivator is the communication of low expectations by mental health personnel, who sometimes underestimate the ability of SMI patients to cope with stress. For example, Millner and colleagues (2015) described a 62-year-old, European-American woman who felt demoralized when her medical and vocational caregivers attempted to dissuade her from taking the kinds of “stressful” jobs that she was interested in.

1.3 Facilitators to work

Research has identified a number of factors that increase the probability of people with SMI finding and keeping jobs. Higher educational level and cognitive functioning, longer previous job histories, less severe symptoms, and lack of co-occurring substance use disorders are associated with increased probability that people with SMI will remain in vocational rehabilitation programs and find employment (Kirsh, 2016).

Job placement assistance is another important factor. One study of vocational rehabilitation services from the Rehabilitation Services Administration at the U.S. Department of Education found that job placement services are key to finding and keeping employment for clients with psychiatric disabilities (Rosenthal et al., 2007). Clients who received other types of services (e.g., counseling and transportation) but did not receive job placement services were significantly less likely to find and maintain employment.

Supported employment programs, in which people with SMI are helped to find competitive jobs (i.e., regular, wage-paying jobs in the community) and are provided with integrated vocational and mental health services, have been particularly successful (Marshal et al., 2014). The most heavily researched supported employment model is the individual placement and support (IPS) model. Eligibility is determined by client interest rather than by traditional criteria, such as diagnosis. Furthermore, IPS clients are allowed to choose the types of jobs they wish to apply for, rather than accept choices made by counselors. They are placed in jobs as soon as possible, rather than after lengthy preliminary training, and once on the job, they receive ongoing support with vocational, social, and mental health issues for as long as necessary.

According to an extensive review conducted by Marshall et al. (2014) of existing research from 1995 through 2009, the success rates of IPS programs placing clients in competitive employment positions ranged from 52% to 60%. The success rates for other types of programs, such as traditional vocational services, sheltered workshop programs, and train-and-place programs, ranged from 23% to 34%. Comparable results have been achieved by IPS programs in Australia (Morris, Waghorn, Robson, Moore, & Edwards, 2014), the Netherlands (Michon et al., 2014), and mainland China (Zhang et al., 2017). In spite of this track record, however, most people with SMI do not receive supported employment services. According to 2014 statistics from the Substance Abuse and Mental Health Services Administration (SAMHSA), only 24.6% of mental health treatment facilities in the United States offered any kind of vocational rehabilitation or employment services, and only 19.6% offered supported employment services (Sherman, Lynch, Teich, & Hudock, 2017). According to 2012 statistics compiled by the National Alliance on Mental Illness (NAMI), only 1.7% of patients treated at state mental health facilities actually received supported employment services.

Another key element cited by people with SMI is emotional support from family members, mental health professionals, and peers who affirm the importance of work and earning a living (Millner et al., 2015). A study comparing a supported employment (SE) program that included peer interaction with another SE program that did not include peer interaction found that participants in the former type of program reported greater overall quality of life improvement (Gold, Macias, & Rodican, 2014).

1.4 Women with SMI and work

Research indicates that there are significant differences between the way women and men experience life with SMI (Manuel, Hinterland, Conover, & Herman, 2012). In some cases, women with SMI appear to experience advantages in the search for employment. For example, one study found that female participants in vocational psychosocial rehabilitation programs experienced lower attrition rates than male participants (Harding et al., 2008). A study of people with schizophrenia in the U.S. found that males were less likely to be employed (Beiser et al., 1994), and this result was replicated in a study in the U.K. (Harrison et al., 1996).

Other research suggests that women with SMI tend to be worse off financially and have fewer job opportunities than men (Manuel et al., 2012). One study found that women with SMI experienced greater difficulty finding jobs than men with SMI, and when they did find jobs, they did not work as many hours (Kirsh, 2016). However, another vocational rehabilitation study of 275 participants with SMI in Boston found no gender differences in employment results (Rogers et al., 1991). There is very little research that would shed light on these contradictory findings.

The extant literature contains studies exploring the experience of women with SMI and studies exploring the experience of adults (i.e., both men and women) with SMI in the workplace. However, they rarely do both. For example, a qualitative study conducted by Manuel et al. (2012) described the experience of women with SMI attempting to reintegrate into the community after hospitalization. Although many insights from this study are likely to apply to women with SMI in the workplace, the study concerns the experience of these women generally in the community, not their experience specifically in the workplace. In another example, a qualitative study by Dunn et al. (2008) focused on adults with SMI in the workplace, but the participants were both men and women. Interestingly, most of the participants quoted in the article by Dunn et al. (2008) are women, but the focus of the article is on adults with SMI in general, not on women with SMI specifically.

1.5 Rationale

The current literature offers studies concerning the general experience of women with SMI and studies concerning the experience of adults with SMI in the workplace. Clearly, more research is needed regarding the experience of women with SMI in the workplace. The present study addresses this gap in the literature by presenting research about the experiences women with SMI specifically with regards to the topic of work. The study explores the strengths of these women and the particular difficulties they face in coping with the world of work, with the goal of providing more specifically targeted recommendations to vocational rehabilitation practitioners.

2 Methods

Participants included 20 women with SMI, who were attending a psychosocial rehabilitation center located in the Northeastern region of the United States. The participants ranged in age from 32 to 66, with a mean age of 50. Demographic data is provided in Table 1.

Table 1
Demographic Characteristics of Participants (N = 20)

Demographic Variable n (%)

Race Ethnicity

White American 12 (60%)

Biracial 5 (25%)

African-American 1 (5%)

Asian-American 1 (5%)

Native-American 1 (5%)

Marital Status

Single 11 (55%)

Divorced 4 (20%)

Unknown 4 (20%)

Married 1 (5%)

Sexual Orientation

Straight/Heterosexual 12 (60%)

Lesbian 4 (20%)

Bisexual 2 (10%)

Pansexual 1 (5%)

Questioning 1 (5%)

Diagnosis

Major Depressive Disorder 10 (50%)

Posttraumatic Stress Disorder 8 (40%)

Anxiety Disorders 7 (35%)

Bipolar Disorder 5 (25%)

Borderline Personality Disorder 4 (20%)

Schizophrenia 3 (15%)

Schizoaffective Disorder 2 (10%)

High Functioning Autism 1 (5%)

Demographic Variable	n	(%)
Race Ethnicity
White American	12	(60%)
Biracial	5	(25%)
African-American	1	(5%)
Asian-American	1	(5%)
Native-American	1	(5%)
Marital Status
Single	11	(55%)
Divorced	4	(20%)
Unknown	4	(20%)
Married	1	(5%)
Sexual Orientation
Straight/Heterosexual	12	(60%)
Lesbian	4	(20%)
Bisexual	2	(10%)
Pansexual	1	(5%)
Questioning	1	(5%)
Diagnosis
Major Depressive Disorder	10	(50%)
Posttraumatic Stress Disorder	8	(40%)
Anxiety Disorders	7	(35%)
Bipolar Disorder	5	(25%)
Borderline Personality Disorder	4	(20%)
Schizophrenia	3	(15%)
Schizoaffective Disorder	2	(10%)
High Functioning Autism	1	(5%)

2.1 Procedure

Participants were recruited via announcements in group meetings and flyers posted at the rehabilitation center. The selection criteria were that participants had to: (1) identify as female; (2) be at least 18 years old; (3) be diagnosed with a serious mental illness (schizophrenia spectrum disorder, severe depression, or bipolar disorder); and (4) have experienced significant impairment of functioning in social, occupational, educational, and/or daily living/self-care activities. Semi-structured interviews were conducted according to an interview guide containing questions relating to demographics, diagnosis, personal experience of SMI, gender discrimination, mistreatment by others, as well as experiences in work, parenting, and romantic relationships.

The university institutional review board approved the study, and participants signed informed consent forms prior to participation. Interviews lasted approximately one hour and occurred over a two-month period in person or by phone. An audio recording and verbatim transcript were created for each interview. In some transcript excerpts, readability was improved by removing or modifying non-lexical conversational sounds, word repetitions, and other extraneous content. Care was taken with these excerpt revisions to preserve the original meaning. Following accepted grounded theory standards (Glaser & Strauss, 1967; Mason, 2010), recruiting and interviewing continued until thematic saturation occurred and interviews produced no major new information.

2.2 Data analysis

The interview data was analyzed using grounded theory methodology, in which the data is coded and then categorized in a bottom-up manner to develop themes from patterns in the data rather than from pre-existing hypotheses (Corbin & Strauss, 2008; Miles & Huberman, 1994). The initial research team consisted of a clinical psychologist (the primary investigator and first author), as well as a clinical psychology doctoral student. In the first stage of the coding process, they created a list of over 100 codes through line-by-line coding of a sample of several interviews, creating the initial codebook. They proceeded to assign these codes to the remaining interview excerpts through line-by-line analysis to complete the codebook. Next, axial coding was conducted to organize the individual codes into broader conceptual categories. Selective coding was used to isolate data pertaining to the topic of work, which was then refined into a set of 6 themes by a team of 2 clinical psychology doctoral students working with the primary investigator and first author. NVivo qualitative analysis software was used to assist with the coding process and organize the data.

2.3 Data quality

The research team used qualitative analysis validity methods to enhance data quality. The original interviewer enhanced her credibility with participants (i.e., the interviewees), and therefore the trustworthiness (Morrow, 2005) of the interviews, by fully discussing with participants her position in the research, her clinical background with women with SMI, and her purpose: to fill in research gaps regarding this population in order to enhance clinical care. The research team kept memos in which they recorded first interpretations of the data and other aspects of the data analysis process (Barbour, 2001). They also used reflexive journaling (Morrow, 2005) to identify researcher biases and positioning in relation to the study that might affect the interviewing, coding, and analysis. Research team members conducted cross-checking of coding to enhance inter-rater reliability (Polkinghorne, 2007) and used triangulation (Barbour, 2001) in the selective coding stage. This included three research team members (i.e., the article authors) cross-verifying themes developed by other team members. Consensus (Edwards, Dattilio, & Bromley, 2004) was used to resolve occasional disagreements regarding identification and interpretation of themes.

3 Results

Qualitative analysis of the 20 interviews with women with SMI revealed the following themes related to work. See Table 2 for a summary.

Table 2
Employment themes of women with serious mental illness (SMI)

Work Themes Definitions

Work Drain Tendency for workplace stress to psychologically deplete women with SMI, often exacerbating their symptoms.

Symptom Visibility Challenges women with SMI may have in hiding their symptoms at work, often leading to adverse consequences.

Work Disclosure The dilemma faced by the women with SMI regarding whether and how much to disclose their mental health challenges to supervisors and coworkers.

Inconsistent Work Difficulties women with SMI face in maintaining steady employment, periodically losing jobs or being forced to quit because of mental health challenges.

Nontraditional Work Phenomenon in which women with SMI adapt to challenges posed by their symptoms and external adversity and find meaningful work by starting their own. businesses, engaging in gender non-conforming work (e.g., carpenter, bouncer), or redefining traditional work roles (e.g., motherhood).

Work Assets Resilience factors that women with SMI demonstrate in employment experiences, including community resources, personal contacts, and personal strengths.

Work Themes	Definitions
Work Drain	Tendency for workplace stress to psychologically deplete women with SMI, often exacerbating their symptoms.
Symptom Visibility	Challenges women with SMI may have in hiding their symptoms at work, often leading to adverse consequences.
Work Disclosure	The dilemma faced by the women with SMI regarding whether and how much to disclose their mental health challenges to supervisors and coworkers.
Inconsistent Work	Difficulties women with SMI face in maintaining steady employment, periodically losing jobs or being forced to quit because of mental health challenges.
Nontraditional Work	Phenomenon in which women with SMI adapt to challenges posed by their symptoms and external adversity and find meaningful work by starting their own. businesses, engaging in gender non-conforming work (e.g., carpenter, bouncer), or redefining traditional work roles (e.g., motherhood).
Work Assets	Resilience factors that women with SMI demonstrate in employment experiences, including community resources, personal contacts, and personal strengths.

3.1 Work drain

Work drain is a theme that emerged from data analysis, referring to the phenomenon in which women with SMI experienced work as depleting their internal resources and/or exacerbating their symptoms. For example, one participant described how her job aggravated her symptoms to the point where she had to leave.

Although that was the beginning of it getting really worse and PTSD sort of getting, coming to a head. I ended up leaving that job because of how it affected me mentally. And so I ended up with no income and unable to work for quite a while.

She highlighted how taxing work can be for a woman with SMI, as well as the possible consequences of this strain, such as loss of job and income.

Another woman described the crippling fatigue she experienced at work and the lack of accommodation by her boss.

Oh, I was slow because I was constantly checking myself ... I didn’t know anybody else but me in the workplace who had a mental health problem. There was obviously only one. I was the only one declared anyway ... because I’m much older than these new things that came in, like reasonable accommodations, like having a cot. I really got tired after lunch, and I really needed, like, an hour’s sleep. And I found some place to sleep and I would just disappear, but the big boss didn’t like that at all. He said, “She’s away from her desk too much ... ”

This participant felt isolated and misunderstood in her workplace, being the only one who disclosed having mental health challenges. She indicated that that the SMI caused her to check and re-check her work compulsively, slowing her down and exhausting her. She perceived that her coworkers and her boss could not understand the strain she was under and her need for rest.

Other participants in this study also indicated that their coworkers’ or employers’ insensitivity toward their fatigue was a major barrier at work. This was reflected in the following excerpt about why one woman stopped working.

It was a lot of things. I was having sleep issues. I think I was definitely having depression issues ... there were all kinds of stuff going on. I had really burned myself out. You know, my bosses were horrible people.

This participant felt overwhelmed by a cascading series of depressive symptoms, which included sleep problems, leading to burnout and friction with her employers. The combination of depression and sleep problems exacerbated the strain of working.

For the women in this study, workplace stress appeared to interact with the challenges of an SMI in several ways. For example, for the woman with PTSD, work stress worsened her mental health symptoms. Conversely, for the woman who tended to re-check her work, symptoms from her SMI made the job more stressful, causing severe fatigue. A reciprocal relationship could develop between workplace stress and the challenges related to the SMI, which participants found acutely draining.

3.2 Symptom visibility

Symptom visibility refers to the difficulty that many of the participants experienced trying to hide their symptoms from bosses and coworkers. The women interviewed for this study were often concerned with how visible their illness was to others. Two aspects of the symptom visibility theme that women spoke about were the difficulty they experienced trying to hide their symptoms and the potential negative consequences if they failed to do so. One woman with severe depression described the distress she felt when others in her workplace pressured her to look happy.

I would get people all the time saying to me, “Smile, smile!” I remember very clearly that, how much that irritated me, you know? I couldn’t hide it. And I wanted to but, if I’m not smiling then I guess I look sad ... My direct supervisor asked me, “Why are you so sad all the time?” in front of a lot of people. And I just said, “That’s my face. That’s just what I look like.” It was very upsetting to me ... I couldn’t help being depressed or looking depressed. It was very hard in the world to try to act okay, and I was anything but okay.

This woman felt under pressure to look as if she was doing well but was not able to hide her ongoing emotional distress. The stress involved in trying hide her condition added to the stress of the SMI itself.

Participants also described the consequences of failing to hide their condition, which ranged from harassment to job loss. One woman indicated that she was repeatedly taunted and called a “fruitcake” by a fellow employee without understanding what she had done to trigger this behavior. Another described being called a “crazy lady” by an assistant manager.

Hostility toward women with SMI may not always be expressed explicitly. One participant recounted being fired from her job without being able to pinpoint the exact reason.

I worked as a respiratory therapist for 15 years, and I was fired at my last job because the supervisor didn’t like me. And that was really the only reason. Because I had all good reviews, you know, yearly reviews and stuff ... I worked the night shift, a twelve-hour night shift, and I wouldn’t sleep during the day ... hardly at all so I was kind of a wreck, but I did my job ... I don’t know how that affected her ... yet, on my reviews I’d have good reviews. I really don’t know what I did ... It was hard to put your finger on it.

She sensed that her symptoms of depression caused the supervisor’s animosity toward her. However, she also described feeling exhausted during the day because of her difficulty sleeping after night shifts. It is probable that her SMI made her particularly vulnerable to the stress of working the night shift, increasing the visibility of her condition.

This theme of symptom visibility provides another example of the kinds of reciprocal stress cycles that were particularly devastating for women with SMI in this study. Attempting to conceal their symptoms could add to the stress of coping with their symptoms in the workplace. In turn, the increasing stress could worsen their symptoms, making their symptoms more visible, thus triggering negative reactions from others, and causing more stress. Moreover, women with SMI reported a specific pressure likely linked to gender expectations for women to appear upbeat and inviting in the workplace, which added to their strain.

3.3 Work disclosure

The theme of work disclosure concerns dilemmas that women with SMI face regarding whether and how much to deliberately disclose their mental health condition to others. The participants’ comments regarding disclosure were mixed. One woman stated, “I haven’t been really open. I haven’t disclosed too much.” Another indicated that she believed it might be a good idea to disclose something about her condition because the employer and fellow employees might be willing to help.

Whatever situation you need - [like] more time to go to therapy - if they know, they might help you make that time. They will support that employee ... That’s why [you] just ... tell them that you have [a] mental [health problem].

As seen in this excerpt, the participants in this study expressed different attitudes about disclosing their conditions in the workplace. On the one hand, revealing their condition could lead to obtaining help that they needed; on the other hand, they might wish to protect their privacy or avoid potential stigma that could result from making their condition visible.

3.4 Inconsistent work

Inconsistent work refers to the fact that some of the women with SMI in this study had a difficult time obtaining and keeping a job. At times, participants found their SMI had not impacted their experience of work, but it had impacted their ability to work consistently and therefore keep their jobs. Their descriptions touch on three of the problems that typically hindered women with SMI, the first problem being the experience of frequent relapses.

I haven’t been well enough consistently to hold down a job consistently. Like, maybe for a few months but then things go wrong. I don’t stay consistently well for very long, and that’s been a major problem.

The second problem was that an intermittent work history became, in itself, a hindrance to finding work. One participant pointed out that, “The fact that there’s not a lot on my resumé could theoretically get in the way.”

A third problem was a motivational deficit, in this case due to the participant’s experience of losing jobs frequently or having to quit because of symptom recurrence.

In practice, I haven’t tried that hard to apply anyway, because I haven’t had consistent mental health for more than a few months at a time, and it just hasn’t worked. And the two jobs that I had, one of them just came to an end. The position was terminated, but the other, I actually quit. So, I was actually - things were going OK and I could’ve helped it, and I quit because I was very unwell and couldn’t do it anymore. And even though it was only a few hours a week, I just couldn’t.

This woman’s experience demonstrates a cycle of discouragement, in which symptoms forced her to quit, which created an expectation of failure, along with a spotty resume that decreased her probability of finding another job, which in turn decreased her motivation to try in the future.

Another variation of this spiral is described in the following account, in which the interaction of workplace stress and SMI diminished the patient’s performance, which in turn created more stress, resulting in the participant being in danger of termination but instead going on disability.

only for a year. Then I had to go out on disability. But ... if it had been anything other than social work, they would have fired me a couple weeks before I left because my job performance was down to zero. They kept me on, and that meant I was able to get this health insurance, which is double my income. I mean, they were really, really good to me. First, I went out on sick leave, then short-term disability, then long-term disability, and then I had to resign because I couldn’t come back to work.

This participant appears to have made an effort to stay in the workforce, but the combination of work stress and SMI drove her backwards inch by inch, first into sick leave, then into short-term disability, then into long-term disability, and finally into quitting. For women with SMI, this disruption in their work histories, with accompanying discouragement, sometimes derailed their attempts to continue to work.

3.5 Nontraditional work

The theme of nontraditional work refers to the tendency of women with SMI to find unconventional jobs in order to adapt to challenges posed by their symptoms and external adversity and pursue meaningful work. One woman with a history of severe sexual trauma worked as a bouncer in nightclubs.

I was full of muscle ... when I moved to [this state]. I continued to lift weights. And then I became a bouncer at the clubs here ... I was never really safe. So I made myself safe.

This participant had a quest to feel safe following the severe sexual trauma that contributed to the onset of her SMI. This led her to take up weight lifting and then to pursue a traditionally male job as a bouncer, both of which helped her to feel a sense of physical and psychological safety.

Similarly, another participant chose a profession dominated by men, in spite of a strong desire to maintain a sense of separation from men. She knew early on in her life that she did not want to work at jobs traditionally associated with women.

I knew I wanted to do nontraditional work. I didn’t know what, but I just knew that I had to do something different. I mean, when I was growing up in the 60 s, women were teachers, or they were nurses, or they were secretaries, none of which I wanted to be. I wanted to work outside, and I wanted to work with my hands ... I went to [an] industrial school. I was the first woman to graduate from the carpentry program and then I went to work in a boat yard ... And that really helped me a lot even though at the time I was a feminist and a separatist.

Social expectations regarding what constitutes a “real” job were a source of irritation to one of the participants, who took pride in running her own business, along with volunteering and creating a community resource for homeless youth.

My daughter one time when she was a teenager said, “What am I supposed to tell my friends you and Dad do?” This one’s mother is a dentist and her father is a lawyer. This one’s – on and on and on and on. I said ... “I have my own business. I ran a family daycare.” [My daughter said,] “That’s not a real job.” I said, “I’m on the Board of Directors for the Kids Clothes Club.” “That’s not a real job.” “I did the Salv–,” “That’s not a real job.” ... I forgot that when I was that age, I needed things in a box.

Like this participant, participants in this study demonstrated creativity and resourcefulness in seeking and attaining jobs, despite the odds against women with SMI. In addition, they often thought outside the box when it came to employment. They performed in male-dominated jobs that enhanced their sense of strength in the face of vulnerability to an SMI or history of sexual trauma. Or, they started their own businesses and engaged in community activism.

3.6 Work assets

The work assets theme refers to positive factors that helped women with SMI cope. There were elements in their environments that they could call on, the main ones being community resources and personal contacts. These resources included a group that provided emotional support for women who felt uncomfortable or intimidated working with men, a workers’ union, and a public assistance program that provided transportation to work. One participant’s boyfriend provided jobs for her and her sons. Another woman who had held only two jobs got both of those positions through people she knew after she was turned down for all the others she applied for. In a third case, a sympathetic boss, whose child had a disability, helped a participant resolve a workplace dispute.

Well, I got help ... My immediate boss wound up helping me because she had a child with Down syndrome. You know, she was like, “When you’re sick, you’re sick. You can’t help it ... ” I think there was a fight about me. And I think she won.

Another participant described how her resourcefulness and creativity enabled her to find jobs in spite of stigma and discrimination.

I got another job by saying, “You shouldn’t be yelling at me, you should be hiring me to yell at me.” And I created a position and a manual for another position at another company. So, it’s all about knowing how to get around the back door and find a need to where, finding a need and doing that.

The same participant described the need to strategize and appeal to male employers through one’s looks.

I’m not talking about your sexuality, I’m not talking about that, but if you use what men kind of look at you, like for instance, if you’re a dumb blonde stereotype, use that dumb blondeness to go through the back door ... and then dye your hair brown, and then shine.

This participant described ways of using sexism to the advantage of women with SMI in order to secure a job and then move on to doing the job competently.

The overall picture presented by the women in this study is that being hired for a job is difficult, and it’s even more difficult for women with SMI. Consequently, these women are forced to use any and all resources, contacts, and breaks that come their way, even if this involves taking advantage of less than empowering stereotypes.

4 Discussion

Grounded theory analysis of the workplace experiences of women with SMI yielded a number of unique insights as well as extensions of the literature on issues pertaining to the experience of women with SMI and work. In general, these findings highlighted that women with SMI face double stigma in the workplace with regard to their gender and mental health experiences. In addition, the intersection of gender and mental health for women with SMI contributes to unique resilience factors in their working lives.

With regard to specific theme findings, work drain demonstrated the reciprocal relationship between workplace stress and symptoms. Symptoms could make working more difficult, and the combined stress of work and SMI could deplete emotional resources to the point of rendering women with SMI unable to work. The current literature on SMI and work tends to discuss in general terms how stigmatization, discrimination, and symptomology act as barriers to work for adults with SMI (Millner et al., 2015; Saavedra et al., 2016). The work drain theme in this study adds to this discussion by portraying the lived reality of stress and fatigue that women with SMI experience at work, along with the manner in which the lack of opportunities for rest and workplace accommodations can hinder their performance.

Symptom visibility highlighted the pressure that women with SMI felt to hide emotional distress and to conform to gender expectations to appear cheerful. Moreover, women could incur negative consequences should they fail to fit gender norms for their mood. This is consistent with research showing that women across cultures are expected to (and in fact do) smile more than men in spite of having similar self-reported emotional experiences (Adams, Hess, & Kleck, 2015). For the participants in this study, knowing that their emotional state was so visible and being unable to hide it confronted them with the aforementioned double stigma of sexism and mental illness stigma, with derogatory labels applied to them like, “crazy lady” or “fruitcake.” The symptom visibility theme also brings into sharp relief the manner in which detectable symptoms isolate women with SMI at work. This is potentially due to the greater role that social relationships play in recovery for women with SMI (Manuel et al., 2012), which adds pressure to appear upbeat and welcoming to others. Additional research should be conducted to examine what gender-related pressures men with SMI may face in the workplace.

The work disclosure theme, in conjunction with the symptom visibility theme, contributes to the literature by emphasizing the double-edged nature of disclosure for women with SMI in the workplace. If they do not disclose, they could miss out on vital accommodations, support, and allowances. Furthermore, not disclosing adds to the stress of having to conceal their symptoms. According to Hielscher and Waghorn (2015), the most common reasons that individuals with mental illness cite for choosing to disclose their condition are (1) obtaining accommodations and support; (2) explaining poor work performance; and (3) relieving stress caused by concealing their condition. On the other hand, if they do disclose they could open themselves to stigma and discrimination. Research in this area is mixed. Some research has shown disclosure to be associated with premature job termination, while other studies have shown disclosure to be associated with longer job duration, and still other studies have shown no relationship (Hielscher & Waghorn, 2015). Some women in this study were tempted or urged by others to deliberately disclose their mental illness to obtain accommodations such as “more time to go to therapy,” as indicated by one participant. Other women avoided disclosure to avoid making themselves targets for the kinds of harassment described in the symptom visibility theme.

Inconsistent work demonstrated the long-term outcomes of the combination of work-related pressures seen in the themes of work drain, symptom visibility, and work disclosure for women with SMI. Some women in the study were forced to leave work repeatedly, creating the kinds of unstable work histories shown in the inconsistent work theme. In turn, variable work histories could make finding future work more difficult, increasing discouragement and demotivation. Previous research suggests a paradox regarding women with SMI and motivation to work. There is considerable evidence showing that both men and women with SMI are strongly motivated to work, along with evidence that women with SMI are particularly motivated and are more inclined than men stay in vocational rehabilitation programs (Harding et al., 2008). However, there is also evidence showing that motivational deficits are a key factor preventing people with SMI from finding work (Saavedra et al., 2016) and that women tend be less successful finding and keeping work (Kirsh, 2016). The inconsistent work theme provides clues to this paradox. Women in this study sometimes experienced so many relapses that they came to doubt their ability to hold a job for any length of time and thus came to see looking for work yet again as pointless. The spiraling pressure they experienced at work could lead to a decrease in performance and potential need for sick leave, short-term and then long-term disability, followed by unemployment. Leaving the workplace was experienced by some as a relief. On the other hand, that relief could be followed by isolation and depression. Though the women continued to desire to work, they reached a point where they “just couldn’t,” given the effects of their symptoms, mistreatment by bosses and coworkers, and lack of workplace accommodations.

Lastly, an important insight contributed by the work assets and nontraditional work themes is the fortitude shown by many of these women in their efforts to obtain and maintain employment. They tended to use whatever contacts, resources, and assets they possessed in order to find and keep jobs. This could include relying on a partner, taking advantage of sexist stereotypes, or creating a new position for themselves in a company. Some women expressed pride in being able to “get around the back door,” and “then shine.” Others pursued occupations not typically associated with women, even if it meant violating gender stereotypes or obtaining training previously reserved for men. The desire to work shown by adults with SMI, along with the pride that they often take in working, has been described by other researchers (Dunn et al., 2008; Harding et al., 2008; Millner et al., 2015; Rosenthal et al., 2007). Consistent with previous research, the women in this study tended to believe strongly in the importance of work. Even those who were less successful in finding and keeping work often made repeated attempts to re-enter the workforce. What the nontraditional work and work assets themes emerging from this study add to the previous research is the resourcefulness that women with SMI demonstrate in their search for meaningful work. Those who obtained work successfully had to strategize and use whatever personal contacts and other assets were available to them. Some were even willing to take physical or financial risks to pursue vocations they found satisfying.

4.1 Vocational rehabilitation implications

Several suggestions for vocational rehabilitation practitioners arise from this study. Clearly there is a need to provide more women with vocational rehabilitation services, and to tailor these services to their unique needs as women. Research has shown that job placement based on client preferences, along with ongoing counseling to deal with psychological and interpersonal issues, is critical to clients’ success (Rosenthal et al., 2007). It is interesting, given previous research showing that women are more likely than men to remain in vocational rehabilitation programs (Harding et al., 2008), that none of the women in this study mentioned utilizing vocational rehabilitation resources to support their ability to seek and retain work. The data collected in this study do not indicate whether the women in this study had access to these kinds of services or, if they did, whether the services proved not useful or were not mentioned for some other reason. The work assets theme in this study underscores the importance to women with SMI of obtaining support and accommodations from a variety of sources, including community agencies, employers, partners, friends, family, and others. Job placement and counseling services are likely to be more successful when combined with sources of support available in the social networks of women with SMI.

The work drain and symptom visibility themes suggest that training in stress management, emotional regulation, and self-soothing skills is likely to be particularly helpful. These kinds of skills can help manage the effects of work drain, reduce performance deterioration, and lessen the chances of relapse. They can also help make symptoms less visible, which can reduce external harassment and stigmatization. In addition, women with SMI may benefit from coaching in various work behaviors that can be hindered by gender socialization in which women are conditioned to avoid assertiveness (Sue & Sue, 2008). This coaching could include advocating for their rights, requesting accommodations, and building relationships with coworkers and employers. This can help manage the kinds of harassment described in symptom visibility and acquire the kinds of useful allies described in work assets.

Vocational rehabilitation practitioners could also help women with SMI explore the issue of when, how much, and to whom they should disclose their mental condition at work. The work disclosure theme showed clearly that this issue is a source of confusion, risk, and stress for women with SMI in work situations. Practitioners can help women with SMI assess the pros and cons of workplace disclosure, anticipate problems, and develop effective solutions that cater to the specific experiences of women with SMI and the double stigma they encounter at work.

This need is not being met consistently by vocational rehabilitation practitioners, even in IPS programs, according to Hielscher & Waghorn (2015), who state that, “clients of IPS supported employment are currently provided with little structured guidance on how to manage their personal information in the workplace” (p. 306). An item was added to the industry standards for IPS programs urging employment counselors to work through the pros and cons of disclosure with clients to develop a disclosure strategy. There is a significant correlation (r = 0.38) between following this standard and successful outcomes, but only 37% of IPS sites were found compliant in a recent study (Hielscher and Waghorn, 2015). The confusion and anxiety indicated by the work disclosure theme highlight the need for vocational rehabilitation practitioners to help their clients manage the disclosure issue.

The inconsistent work theme highlights the need for working women with SMI to have a well-organized, detailed, relapse prevention plan. Practitioners who are working with women with SMI should help them learn how to recognize triggers and warning signs of a relapse and how to develop and utilize specific coping plans. These relapse prevention and coping plans can integrate clear descriptions of the kinds of strengths shown in the work assets and nontraditional work themes that women with SMI may uniquely demonstrate. Based on our findings, rehabilitation practitioners can identify worker strengths pertaining to women’s abilities to pursue unconventional work outside of traditional gender norms, gender socialization to utilize work relationships to their advantage, and their tendency to be savvy navigators of gender constraints in the workplace.

4.2 Limitations and future research

The present study includes several limitations that suggest directions for future research. While qualitative analysis typically involves a smaller sample size to involve in-depth study, this element poses limitations to generalizability. In addition, qualitative research often focuses on individual experiences of participants within a group. Further research could be done on a larger, more geographically distributed sample using quantitative techniques to arrive at more general conclusions about the average, shared experiences of women with SMI. Additional research should be conducted to explore the experiences of men with SMI in the workplace as well. The women in this study were not asked specifically whether vocational services were available to them or whether they had used such services. The fact that the women in this study mentioned a variety of helpful assets but did not mention vocational rehabilitation services raises interesting questions. Were vocational services available but not found useful? Were there barriers to using such services? More research is needed about variables that affect the extent to which women with SMI have the capability and desire to make use of vocational rehabilitation services. Lastly, while multiple data quality measures were utilized in the present study to enhance methodological rigor, the process of member-checking findings with participants would enhance data quality and could be used in future research in this area.

5 Conclusion

Women with SMI in the workforce face a combination of challenges caused by their symptoms and by external reactions to their symptoms. Some may be disadvantaged when their symptoms interfere with work performance. Others may be unable to hide their symptoms, and employers and coworkers may react with resentment or stigma. Interactions between typical workplace stress, the stress of living with SMI, and external rejection can deplete internal resources, which can initiate a cycle of increasing distress and decreasing ability to cope. This can ultimately lead to unemployment. However, women with SMI often show exceptional determination and ability to overcome obstacles. Vocational rehabilitation practitioners can help women with SMI to leverage their strengths in order to gain greater satisfaction and meaning from work. Moreover, policy change is needed to provide greater rights, accommodations, and policy enforcement to support the needs of women and others with SMI in the workplace.

Conflict of interest

None to report.

Footnotes

Acknowledgments

This study was funded by Fielding Graduate University. The authors would like to thank Danielle Drake, MA, Megan Brubaker, MS, and Eugene Boyle for research assistance with data entry, coding, and presentation of findings from the study, respectively. The authors would also like to thanks Zlatka Russinova, PhD and E. Sally Rogers, EdD for their initial support of this study.

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