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Benefits and Drawbacks of Employment: Perspectives of People with Mental

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Article  in  Qualitative Health Research · April 2004

DOI: 10.1177/1049732303261867 · Source: PubMed

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QUALITATIVE
Honey / MENTAL
HEALTH
ILLNESS
RESEARCH
AND EMPLOYMENT
/ March 2004 10.1177/1049732303261867
ARTICLE

Articles

Benefits and Drawbacks of Employment:

Perspectives of People With Mental Illness

Anne Honey

In this article, the author presents the perspectives of people with mental illness about the
benefits and drawbacks of employment, what factors influence these, and how they affect
consumers’ decisions and actions. Forty-one consumers of mental health services partici-
pated in 76 in-depth interviews and two focus groups. The author coded data inductively
and analyzed them using grounded theory method. The results demonstrate that the benefits
and drawbacks of employment are experienced in six domains. Individuals’ perceptions of
benefits and drawbacks are influenced by individual and contextual factors, are dynamic
over time, and are instrumental in determining their employment-related actions. The find-
ings suggest several areas for future exploration with a view to improving policy and
practice in employment for people with mental illness.

Keywords: mental illness; employment; consumer perspectives

A number of benefits for people with mental illness are attributed to paid
employment. Recent government reports in Australia have asserted that hav-
ing a job increases confidence, self-esteem, and feelings of being productive and
normal; affords social status, independence, and financial security; promotes social
interaction, community participation, and personal and professional growth;
ensures purposeful use of time; supports mental health; and offers challenge, stim-
ulation, and personal satisfaction (e.g., Baume & Kay, 1995; Commonwealth
Department of Health and Family Services, 1997; Commonwealth of Australia,
1993; Human Rights and Equal Opportunity Commission, 1993; Reark Research,
1993).
The empirical evidence for these benefits, however, is not conclusive. Based on
his review of the literature, West (1992) argued that social interaction and support at
work were not necessarily experienced by people with disabilities and that even

AUTHOR’S NOTE: Ethical approval for this study was obtained from the University of Sydney Human
Ethics Committee. This study was made possible by an Australian Postgraduate Award scholarship from
the Australian government. Thanks are due to my Ph.D. supervisor, Associate Professor Gwynnyth
Llewellyn, for her guidance and support in this project. Thanks also to A/P Christine Halse from the Uni-
versity of Western Sydney, and Peter Williamson and Dr. Ruth Beltran from the University of Sydney for
reading and commenting on drafts of this article.
QUALITATIVE HEALTH RESEARCH, Vol. 14 No. 3, March 2004 381-395
DOI: 10.1177/1049732303261867
© 2004 Sage Publications
381
382 QUALITATIVE HEALTH RESEARCH / March 2004

when they did exist, they were often limited to working hours and work-related
matters and thus could not be expected to provide more general social support.
Some researchers have found significant associations between employment and
self-esteem but have not established causal direction (Van Dongen, 1996, 1998) or
have reported small effect sizes (Bond et al., 2001). Others have failed to find signifi-
cant relationships between self-esteem or self-perception and employment (Mow-
bray, Bybee, Harris, & McCrohan, 1995; Torrey, Mueser, McHugo, & Drake, 2000).
Kirsh (2000) has provided a brief review of findings on the relationship between
employment and overall life satisfaction or quality of life, noting inconsistent and
inconclusive findings. One study found that measures of self-efficacy, self-esteem,
and life satisfaction were more strongly related to a recent change in vocational sta-
tus than to a static measure of vocational status (Arns & Linney, 1993), suggesting
that some benefits might not be lasting.
Although it is not definitive, research does suggest that employment might be
beneficial for the mental health of people with mental illness. Macrostatistical evi-
dence shows higher rates of hospital admissions during economic slumps and more
successful rehabilitation in full-employment economies (Warner, 1994). Large
population-based studies indicate that unemployment is bad for the mental health
of many people with mental illness through its impact on their financial status
(Bruce, Takeuchi, & Leaf, 1991; Weich & Lewis, 1998). Some clinical trials also sug-
gest that employment might be associated with lower symptom levels for people
with mental illness (Bell & Lysaker, 1997; Bell, Lysaker, & Milstein, 1996; Bell,
Milstein, & Lysaker, 1993a, 1993b; Bond et al., 2001; Mueser et al., 1997). These
results are not conclusive, however. Bell and his colleagues reported positive effects
from a work program in a sheltered and supportive setting that might not hold true
for people in other employment situations (Bell & Lysaker, 1997; Bell, Lysaker, et al.,
1996; Bell, Milstein, et al., 1993a, 1993b). Mueser et al. (1997) found in their con-
trolled study that although people who were working at 18-month follow-up
tended to be less symptomatic than those who were unemployed, the symptoms of
the workers had not improved significantly over the 18 months of the study. They
suggested that their positive findings were probably partly influenced by better
outcomes’ being experienced by less symptomatic participants. Bond et al. (2001)
found a significant difference in symptom levels after 18 months between a compet-
itively employed group and a no work–minimal work group; however, the symp-
toms experienced by most participants in this study were at subclinical levels, so it
is uncertain whether the same pattern would occur with a more symptomatic
group.
It is unclear whether the lack of substantiation in quantitative studies of bene-
fits of employment that are widely assumed to exist is due to the absence of wide-
spread effects or to methodological issues, such as difficulties with quantification of
benefits (such as self-esteem and life satisfaction) and the absence of studies to
assess benefits over the long term.
In contrast to the clinical trials described above, researchers who have sought
the views of people with mental illness have repeatedly reported numerous benefits
of being employed. These include money, regular activity, a sense of purpose or
focus, personal development, opportunities to socialize, social acceptance, status,
improved mental health, self-esteem, and self-image (Bedell, 1998; Graffam &
Naccarella, 1997; Kirsh, 2000; McCrohan, Mowbray, Bybee, & Harris, 1994; Scheid &
 Honey / MENTAL ILLNESS AND EMPLOYMENT 383

Anderson, 1995; Van Dongen, 1996). These studies have also reported that people
with mental illness see employment as having some drawbacks. These include the
restrictions on other activities that arise from job demands and time constraints,
problems adjusting to the structure and routine of employment, negative social
experiences, tiredness, stress, and experiences that reduce self-esteem (Bedell, 1998;
Graffam & Naccarella, 1997; Harris et al., 1997; Van Dongen, 1996). These stud-
ies have reported the benefits and drawbacks of employment in a descriptive,
generalized, and isolated manner without considering how they relate to other
employment-related issues or how they vary between individuals. In an exception,
Strong (1998) found that the benefits of working perceived by her partici-
pants depended on their relationship with their illness. Four themes were identi-
fied—living with a label, becoming a capable person with a future, getting on with
life, and finding a place in this world—and the theme currently foremost in partici-
pants’ lives influenced the benefits and meanings attributed to work. As this study
focused on the relationship of work to illness and recovery, any other factors affect-
ing participants’ perceptions of benefits were not considered. Kirsh (2000) reported
that participants perceived a need to balance the positive effects of employment,
such as structure, productivity, and financial gain, with the negative effects, such as
work stress; however, it was not clear what form this balancing took or what its
consequences were.
The studies reviewed here do not explore how the benefits and drawbacks
experienced might vary between individuals or between different jobs. They do not
explore what other factors might affect benefits and drawbacks. It is also uncertain
how perceived benefits and drawbacks affect the willingness (or otherwise) of peo-
ple with mental illness to engage in employment opportunities.

THE CURRENT STUDY

In this article, I am reporting from a larger study in which a theory was formulated
to explain the processes by which people with mental illness engage in relation to
employment. The purposes of this article are to clarify the nature of benefits and
drawbacks of employment from the perspectives of people with mental illness, to
illuminate the factors that influence these, and to explore their impact on employ-
ment experiences and outcomes.
In the context of this article, the terms people with mental illness and consumers
(i.e., consumers of mental health services) are used interchangeably and refer to peo-
ple who have experienced serious mental illness and who use psychiatric services.

METHOD

Qualitative research methods were used in this study, and data were gathered di-
rectly from people with mental illness. Unlike in other qualitative studies, I drew
data from unstructured interviews with participants about their opinions, values,
and experiences with regard to employment rather than from participants’ answers
to specific questions (Bedell, 1998; Graffam & Naccarella, 1997; McCrohan et al.,
1994; Van Dongen, 1996) or responses to specific issues (Harris et al., 1997; Kirsh,
384 QUALITATIVE HEALTH RESEARCH / March 2004

2000; Strong, 1998). This unstructured approach allowed identification of the bene-
fits and drawbacks that were most important to participants, the considerations
that influenced their perceptions of benefits and drawbacks, and the consequences
of these perceptions.
I performed this study using the grounded theory method (Glaser, 1978, 1992;
Glaser & Strauss, 1969). A critical feature of grounded theory is theoretical
sampling, and this was a determining influence on the way in which this project
evolved. Theoretical sampling is the process of concurrent collection, coding, and
analysis of data, where ongoing data collection is dictated by the development of
the emerging theory (Glaser & Strauss, 1969). One of the most important aspects of
theoretical sampling is that “the researcher can make shifts of plan and emphasis
early in the research process so that the data gathered reflects what is occurring in
the field rather than speculation about what cannot or should have been observed”
(Glaser, 1978, p. 38). Some of the ways in which the emerging codes influenced sam-
ple selection and data collection are described below.

Participants
Participants in this study were consumers of mental health services in Sydney. They
were not required to provide a diagnosis to participate in the study but were consid-
ered eligible if they used services designed for people with serious mental illness
and wished to participate in a study about such people. I recruited the first 5 partici-
pants through specialist psychiatric employment agencies, as my original intention
had been to limit the study to people who were involved with competitive employ-
ment. It became apparent during data analysis, however, that it was specific fea-
tures of jobs rather than the distinction between competitive and other types of
employment that appeared most relevant to participants, and that the benefits and
drawbacks anticipated were just as important to decision making as those being
experienced. Therefore, I sought participants who were unemployed or were
involved in noncompetitive forms of employment and broadened the area of inter-
est from competitive employment to actions, beliefs, and perspectives related to
employment more generally. I recruited participants from three mental health cen-
ters and one consumer group. I chose these to maximize the variation between par-
ticipants, particularly in terms of work status, types of employment, levels of func-
tioning, and support required. Service staff told some participants about the project,
and I explained the project to others at client meetings. I did not have access to
potential participants’ names or contact details until they agreed to this. I then pro-
vided participants with information sheets, the contents of which I also explained
verbally. I encouraged participants to ask any questions before they provided their
informed consent to be interviewed.
I collected demographic information informally in the context of unstructured
interviews. Participants were in a range of employment situations. Fifteen were in
competitive employment, whereas 9 worked within the mental health system, for
example in business services, consumer advocacy, or paid work rehabilitation pro-
grams. One participant held both types of job at once. Sixteen participants worked
part-time, whereas 9 worked full-time. Fifteen participants were unemployed. Five
of these were job seeking, and 1 was a student. One group participant did not
 Honey / MENTAL ILLNESS AND EMPLOYMENT 385

discuss employment status. Participants held a wide variety of jobs. These included
assistant in nursing, packer, kitchen hand, cleaner, factory worker, clerical worker,
consumer advocate, computer programmer, teacher, and senior public servant. Six-
teen participants were female, and 25 were male. They were in their 20s (11), 30s
(13), 40s (9) and 50s (8). Although not required to disclose their diagnosis, 23 partici-
pants did so, and of these, 13 had been diagnosed with schizophrenia, 5 with bipolar
disorder, 4 with depression, and 1 with drug-induced psychosis.

Data Collection
I performed in-depth interviews, the primary form of data collection, using the
recursive model as described in Minichiello, Aroni, Timewell, and Alexander
(1990). This is an unstructured form of in-depth interviewing in which interviews
are allowed to proceed along the lines of a conversation. I used it to enable each par-
ticipant to discuss what was most important about his or her employment-related
beliefs and experiences. Most data were tape-recorded; however, where this was
impractical due to the setting, or participants were uncomfortable with being
recorded, I took written notes and wrote up detailed field notes as soon as possible
after each interview. This occurred in individual interviews with 6 participants and
in one focus group of 8 participants. For all but one participant, repeated interviews
meant that the accuracy of the data could be checked subsequently.
I originally intended that a smaller total number of participants would all be
interviewed over time; however, it became apparent through analysis of repeated
interviews with the first 5 participants that people were engaging not in a linear pro-
cess but, rather, in a cyclical process that could be investigated from any point
within that process. I therefore decided to maximize the range of participants and
expand and develop the emerging theory through interviewing other participants
once only. Data from 76 individual interviews with 36 participants were supple-
mented by two focus groups. The focus groups were organized by staff contacts,
because they believed that this was the best way for me to make contact with partici-
pants in an informal and nonthreatening way. Focus groups included 12 par-
ticipants, 7 of whom were also interviewed individually. Focus groups lasted for
between 1 and 2 hours and were, like individual interviews, fairly unstructured. I
used broad discussion questions such as What does having a job mean in your lives?
to start discussion, which then progressed according to group interactions, with
participants’ being encouraged to discuss whatever was most important to them in
relation to employment. Focus groups differ from individual interviews in that they
“allow respondents to react to and build upon the responses of other group mem-
bers” (Stewart & Shamdasani, 1990, p. 16). They can, therefore, result in the expres-
sion of ideas that would not have been forthcoming in individual interviews. The
interaction between participants also means, however, that responses are not inde-
pendent of each other, and bias can result from the reluctance of some members to
express contrary opinions. This danger was somewhat counteracted for 7 of the
group participants, who were also interviewed separately, and 2 of these people did
express disagreement with comments made by other members of the group. In gen-
eral, group discussions tended to focus more on general issues and opinions and
less on personal experiences than the individual interviews did. The data from
386 QUALITATIVE HEALTH RESEARCH / March 2004

focus groups were used not as a test of the data obtained from interviews but as a
different “slice of data” (Glaser & Strauss, 1969, p. 65).

Data Analysis
I coded each interview and focus group discussion according to the principles out-
lined by Glaser (Glaser, 1978; Glaser, 1992; Glaser & Strauss, 1969). I used the
NUD*IST computer program to assist in coding and data management and devel-
oped conceptual codes from the data. For example, I coded the statement “being
interactive with other people brings me back into reality” as both Opportunities for
Social Interaction and Improved Mental Health. I used constant comparative analy-
sis of incidents and concepts to develop and refine concepts and to group these into
more abstract concepts, known as categories. I recognized both of the codes above
as possible Benefits of Employment and identified the possibility of a causal link
between them. I also coded Opportunities for Social Interaction as a job property
and specifically one that was desirable and had the potential to influence the Bene-
fits of Employment. By examining the contexts in which people discussed Benefits
of Employment and Drawbacks of Employment, it became apparent that they were
engaging in a process of Weighing Up, which influenced their decisions about what
to do with regard to employment. I continued to collect data until theoretical satura-
tion, when additional data were no longer modifying the codes or revealing new
characteristics of the codes and no new codes were emerging (Glaser, 1978, p. 62).

RESULTS

Grounded Theory
In this article, I propose a theory that explains the place of perceived benefits and
drawbacks of employment in the vocational experiences and actions of people with
mental illness. People with mental illness engage in an active process of weighing
up the perceived benefits of employment against the perceived drawbacks of
employment. These benefits and drawbacks are neither separate nor independent.
Within each of six domains, experiences and beliefs exist along a continuum from
very negative to very positive. Experiences in the different domains influenced each
other. In the process of weighing up, people with mental illness take into account
and are influenced by their broad social context; their social networks; their individ-
ual characteristics, including their mental illness; the properties of jobs; the impact
of disclosure of mental illness; and the available alternatives to employment. The
outcome of this weighing-up process influences the decisions that people with
mental illness make about what actions to take with regard to employment and
their satisfaction with their employment situations.
In the following sections, I discuss the study’s findings in relation to the inter-
related benefits and drawbacks of employment, the process of weighing up these
benefits and drawbacks, the factors that influenced how people perceived benefits
and drawbacks, and the ways in which the weighing-up process influenced
employment experiences. Participants’ names and any identifying details have
been changed to protect their privacy.
 Honey / MENTAL ILLNESS AND EMPLOYMENT 387

TABLE 1: Sample Quotes Illustrating Benefits and Drawbacks

Money
Purposeful and meaningful activity
Growth and development
Social participation and belonging
Self-image and self-esteem
Mental health
If you got job and you got wallet with wages . . . you feel
better . . . You need a lot of things and [if] you see them
and you have no money to buy them, [it] make(s) you
depressed.
I wanted to be paid for it, a little bit anyway, but the
money’s not the issue, as long as the system changes.
It’s like the satisfaction of actually doing something dur-
ing the day . . . and then coming home after work and
like, feeling pretty good that you’ve had a constructive
sort of day.
I look at the clock all day . . . you’re wishing your life
away aren’t you?
I think it does give you a lot . . . more personality and that,
than if you didn’t go to work and it helps, it’s going to
help you isn’t it, in the long run.
When you’ve been out of work a while, psychologically
you um, go back into the workplace and . . . sometimes
it’s harder the second time around than doing it all the
time.
We all feel a need to belong. To be part of a society. And if
work is the simplest way we do that, we work. Because
it’s a way of becoming accepted. If you belong to a
group at work, you actually have been accepted by soci-
ety. It has great social implications.
What really got to me one day is . . . everyone’s listening
and everyone’s watching and he’s going [aggressively]
“You do what I want, when I want and then we’ll get on
good.”
You can often feel that you’re nothing when you’re not
[employed]. You know that that’s not true but that’s
how a lot of people look at you and that’s how, you
know, you often feel.
You think “look, I’ve had five or ten jobs and I can’t keep
one.”
Work for me was a way to get well and stay well and just
keep on keeping on.
I think it was the stress of the job that caused it, getting ill.

The Benefits and Drawbacks of Employment

Participants in this study experienced the drawbacks of employment in six
domains: money, purposeful and meaningful activity, growth and development,
social participation and belonging, self-esteem, and mental health. Within each
domain, participants experienced or anticipated both benefits and drawbacks from
being employed. For example in the domain of purposeful and meaningful activity,
many participants believed that employment gave them something to do, a reason
to get up and out of the house, a needed routine, and the opportunity to use their
skills, contribute to society, and “make something” out of their lives. Some partici-
pants, however, experienced work as boring, unpleasant, and pointless, and found
that their jobs took up time and energy that they could otherwise use for valued
activities such as voluntary work, housekeeping, and leisure activities. For some,
therefore, having a job reduced the time they spent in activities they regarded as
388 QUALITATIVE HEALTH RESEARCH / March 2004

purposeful and meaningful. People also differed in the importance they attached to
the various benefits and drawbacks. For example, money was viewed almost uni-
versally as a job benefit; however, for some it was the sole motivator, whereas for
others it was a secondary or taken-for-granted benefit. Table 1 contains examples
from these domains in the form of quotes from participants.
The various benefits and drawbacks were not independent but, rather, influ-
enced each other. For example, many of the self-esteem benefits of employment
were attributed to the other benefits: meaningful activity (especially contributing to
society), money, social status, and the feeling of being able to improve oneself and
one’s position in life. As another example, where employment was experienced as a
source of stressful or distressing social interactions and social rejection, both self-
image and mental health also suffered. High levels of benefits in one domain, how-
ever, were sometimes associated with drawbacks in another domain, making com-
promises necessary. For example, Bill was searching for a job that would provide
greater monetary benefits and higher social status than his current job but realized
that many jobs fitting these criteria were also more stressful and, therefore, might be
detrimental to his mental health.

Weighing Up
Participants engaged in a process of weighing up the benefits of employment
against the drawbacks. They did this at two levels. First, participants assessed the
benefits and drawbacks of being employed to decide whether they wanted a job.
They also compared jobs or types of jobs in terms of benefits and drawbacks to help
them choose a course of action to maximize the benefits and minimize the draw-
backs. The weighing up of benefits and drawbacks was sometimes acknowledged
consciously, as when a participant decided that a job was “not worth it” and left.
However, it was sometimes unrecognized, embedded, for example, in continuing
to go to work and fulfill the job requirements. Because a number of factors affected
the benefits and drawbacks of employment that participants perceived, and
because these factors changed over time, participants evaluated and weighed up
the benefits and drawbacks of their jobs, and of employment in general, on an
ongoing basis.
Weighing up, particularly of anticipated jobs, could be undertaken with vary-
ing degrees of thoroughness. Some participants did extensive research into dif-
ferent jobs and considered many job properties, whereas others considered only a
few known features. For example, Donald was thinking of getting a truck license,
because his friend had told him that it paid well. By contrast, Eddie had definite
ideas about what he was looking for in terms of career prospects: cleanliness of the
physical environment, social status, and the ability to help others through his work.
He talked to a career counselor about the demands of and entry requirements for
various options before making his decision.

Factors Affecting the Benefits and Drawbacks Experienced

I found that six individual and contextual factors influenced participants’ percep-
tions of the benefits and drawbacks of employment. These are depicted in Figure 1
and described in the remainder of this section.
 Honey / MENTAL ILLNESS AND EMPLOYMENT 389

Employment The
and Individual Perceived
Disability in Social and their Job Disclosure alternatives
Australian Networks Mental Properties to
Society Illness employment

Benefits of Drawbacks of
Employment Employment

WEIGHING
UP
FIGURE 1: Weighing Up

Employment and Disability in Australian Society

The Australian social context was seen as a major determinant of the benefits that
participants anticipated they would and did obtain from employment. For exam-
ple, the perceived importance of employment to identity and social status in Aus-
tralia made social acceptance and self-image major benefits of having a job. Many
participants spoke of the regularity with which the question “What do you do?”
was asked. Claude for example, thought that he would “get the flick” in a social sit-
uation if he could not say that he had a job. Another example is that the social secu-
rity system provides only a basic income for people with disabilities who cannot
work. As Bill noted, “You just exist on it.” Gaining money from employment, there-
fore, although not necessary for survival, was seen as important for quality of life.

Social Networks

Participants’ social networks affected how they perceived the benefits and draw-
backs of employment by the messages they transmitted and the support (or other-
wise) they provided. Luke, for example, wanted to get a job to meet people who did
not have mental illness, as his father kept telling him that “you shouldn’t hang
around people with mental illness all the time.” Others described gaining self-
esteem from having a job because of long-emphasized family values, such as hard
work and financial independence. When support from work colleagues was forth-
390 QUALITATIVE HEALTH RESEARCH / March 2004

coming, participants reported experiencing feelings of belonging, greater enjoy-

ment, and reduced stress at work. Similarly, support also helped participants cope
better with the unfavorable consequences of unemployment, such as boredom,
isolation, and low self-esteem.

The Individual and His or Her Mental Illness

Individual factors, including mental illness, were also important in determining the
benefits and drawbacks of employment. In general, mental illness tended to reduce
the benefits and increase the drawbacks of employment. Some participants said
that the effects of their mental illness restricted their choice of jobs, so that the jobs
they felt able to do were undesirable to them, providing few benefits. For example,
prior to becoming ill, Brian had aspired to a high-income, high-status job but was
now working in a fairly poorly paid, mostly manual job. He said that he could have
a better job if he could handle more stress and that “I’m held back just because I’m
schizophrenic . . . I could’ve easily passed university if I wasn’t schizophrenic.”
Mental illness also affected benefits and drawbacks more directly. For example, the
difficulties with social interaction experienced by some participants reduced the
social benefits they felt they could gain from a job. In some instances, however, men-
tal illness could make a benefit of employment seem more important and valuable.
For example, some participants saw lack of energy as a real barrier to their partici-
pation in nonwork pursuits, and the obligatory quality of a paid job provided the
needed motivation to engage in activity. The impact of mental illness on employ-
ment for people in this study is described in greater detail elsewhere (Honey, 2003).
Although they were not examined in detail in this study, other individual and
circumstantial factors, such as personality, values, financial situation, and work and
education history, also appeared to be important to the benefits and drawbacks per-
ceived. For example, the need for money was a deciding factor in Rob’s return to
work after an illness, because he had a loan on some stereo and computer equip-
ment that he did not want to lose.

Job Properties

The jobs that participants held or sought had properties that greatly influenced the
benefits and drawbacks experienced or anticipated. These properties related to
hours, pay, basis of employment, skills and qualifications required, stability, geo-
graphic location, physical environment, productivity demands, nature of tasks per-
formed, resources available, opportunities available, product, ethical soundness,
autonomy, place in the hierarchy, job status, accommodations available, and social
environment. Cassie, for example, felt that her job was good for her self-esteem
because she was in a senior position, she was able to make use of her skills and qual-
ifications, she believed that her work had social value, and her colleagues were sup-
portive and appreciated her skills.

Disclosure

Benefits and drawbacks were also influenced by whether a participant disclosed his
or her mental illness to their employer and/or coworkers. On the positive side, dis-
closure could result in reduced stress, increased support, more suitable job proper-
 Honey / MENTAL ILLNESS AND EMPLOYMENT 391

ties (where accommodations were made), and improved self-image (through being
honest, doing the “right thing,” and being accepted with the illness). Many par-
ticipants, however, reported negative repercussions of disclosure in competitive
employment. These included negative changes to job properties (due to discrim-
ination), stress, and being socially “ostracized” or teased. Whether the impact or
anticipated impact of disclosure on the benefits and drawbacks of employment was
positive or negative depended on the individual and his or her workplace. Ian, for
example, chose not to disclose his illness at work, because he did not think that it
significantly affected his ability to do the job, he did not regard his boss as a likely
source of support, and he believed that his workmates would harass or reject him if
they knew about his mental illness.

Perceived Alternatives to Employment

The ways in which participants viewed employment and unemployment were

affected by the other activities in which they engaged or wanted to engage, for
example, mental health center activities, voluntary work, and leisure activities.
These alternative activities provided many benefits, which affected the net benefits
participants saw employment as offering. For example, Dorothy said that she pre-
ferred the social interactions that come with voluntary work to paid work, as “the
people are nice to you—they don’t sort of yell at you when you can’t do things.”
Barry enjoyed the opportunity to learn and grow through volunteer work at the
mental health center. His previous jobs had, because of mental health issues, been
below his abilities and, therefore, provided few opportunities for development.
Brian, on the other hand, said that if he did not go to work, he would “sit here at
home wondering what am I going to do . . . till I drive myself batty.”
The six factors describe above often influenced each other. For example, the job
properties that participants looked for and the properties of jobs they were able to
get were influenced by individual factors, such as skills, interests, and the effects of
mental illness, and factors within Australian society, such as job availability and
community stereotypes (for example, that people with mental illness are suitable
only for simple, manual jobs). Job properties could also be influenced by disclosure
through, for example, features of the job being changed to accommodate the mental
illness or through the negative impact of stigma and discrimination.
Each of the six factors, to varying degrees, is susceptible to change over time.
Social networks can shift, job characteristics can be altered, an undisclosed mental
illness may be revealed, and alternative opportunities might arise or disappear.
Changes to government policy, particularly with regard to social security, can alter
the balance of benefits and drawbacks. Individuals’ circumstances and mental
health status change over time. This means that benefits and drawbacks are not nec-
essarily stable over time but changeable for each individual.

Impact of Weighing Up on Employment Experiences

The outcome of the weighing-up process significantly influenced consumers’ em-
ployment decisions, actions, and experiences. Participants actively worked toward
obtaining or maintaining employment only when the benefits of employment out-
weighed the drawbacks. The desirability of a particular job depended on its ratio of
392 QUALITATIVE HEALTH RESEARCH / March 2004

perceived benefits to drawbacks compared to that of other jobs. This influenced not
only participants’ actions aimed at getting or keeping a particular job but also their
level of satisfaction with a current job.
Benefits and drawbacks were not, however, the only influence on employment-
related decisions and actions. Participants also took into consideration the actions
or strategies required to gain or maintain a job, the resources needed to undertake
these strategies, and their likelihood of success. For example, Tanya believed that
competitive employment would be extremely beneficial for her and could see few
drawbacks. Despite this, she had recently given up job seeking because, based on
her experiences, she believed that her chances of getting a job were so low that it
was not worth the input of time, effort, and emotional energy that job seeking re-
quired. Other participants stayed in jobs that they regarded as providing minimal
net benefits, because they did not feel confident that they would be able to maintain
a better job.

DISCUSSION AND IMPLICATIONS

The results presented in this article expand on previous research by illuminating the
ways in which benefits and drawbacks fit into the wider picture. Benefits and draw-
backs of employment are shown in their context in terms of what factors affect in-
dividuals’ perceptions of the benefits and drawbacks and how they, in turn, affect
consumers’ decisions and actions. Knowledge of this process can be used by peo-
ple with mental illness as an aid to decision making through articulating and clari-
fying what was previously unacknowledged or taken for granted. By overtly con-
sidering their own needs, priorities, and values in each of the domains, and by
considering the potential for particular jobs and circumstances to affect these
domains, individuals can take more features into account and identify areas need-
ing further exploration and clarification. Vocational workers can use the model to
understand better their clients’ actions and experiences and to help clients to clarify
and articulate their decision-making processes. The model can help clinicians and
researchers to understand why some people do not want jobs as well as why others
do. The results of this study suggest a number of specific areas warranting further
exploration.
For people who are unemployed or considering a job change, weighing up the
benefits and drawbacks of employment involves a great deal of prediction. For
those who have limited work experience, who have been unemployed for a long
time, or who have not worked since the onset of their mental illness, their ability to
predict relevant factors might be limited. In addition, although some people con-
sider many relevant factors and seek information to help them decide, others con-
sider only the most apparent benefits and drawbacks. Some people with mental ill-
ness might, therefore, benefit from vocational counseling specifically directed at
helping them to overtly identify and clarify the benefits and drawbacks most rel-
evant and important to them and to anticipate the extent to which these will be
realized in particular job situations. Investigation of how the number and types of
factors considered influence consumers’ job choices, actions, and outcomes is war-
ranted. Further research is also needed to investigate the relationship between
anticipated and realized benefits of employment and what influences this
 Honey / MENTAL ILLNESS AND EMPLOYMENT 393

relationship. There might be substantial differences, and practitioners could use

knowledge about these to help consumers to close this gap.
For many people, however, there will be no substitute for firsthand experience.
Although a job that lasts for only a few days or a few hours is undesirable, it could
help people with mental illness to move toward achieving a vocational outcome
that is satisfactory to them by increasing their knowledge about the benefits and
drawbacks of employment. Viewed in this way, experiences that might otherwise
be considered failures can be examined meaningfully and treated as valuable learn-
ing experiences.
The dynamic nature of the factors affecting benefits and drawbacks means that
it cannot be assumed that a job will continue to be beneficial for an individual. By
increasing the proficiency with which they evaluate benefits and drawbacks on a
continuing basis, consumers will be in a better position to make ongoing decisions
about their work situations to maximize the benefits achieved. For some, ongoing
support, evaluation, and job development might be warranted.
The findings have a number of implications for future research. The existence of
the continuum of experiences from negative to positive within each domain might
help to explain why hypothetico-deductive research has not provided conclusive
evidence for some of the benefits identified in consumer-focused research. Within a
particular domain, only some people in some situations perceive positive benefits,
whereas for other people, the impact of employment within that domain might be
negative. Further research is needed to clarify the relationship between consumers’
perceptions of the benefits and drawbacks of employment and those benefits and
drawbacks that are measurable through standardized assessments. This would
help to integrate the hypothetico-deductive with the consumer-focused literature in
a more meaningful way.
Further study is needed into the ways in which government policies affect per-
ceived benefits and drawbacks of employment. An obvious example is that in Aus-
tralia, if a person with mental illness does not receive a pension, he or she is not enti-
tled to subsidized medications. This can reduce considerably the economic benefits
offered by full-time employment. Furthermore, the absence of after-hours mental
health services means, for some consumers, that being employed decreases their
access to such services, which might compromise their mental health, a major draw-
back. These sorts of issues could be important considerations for policy makers
wishing to encourage people with mental illness to engage in actions that could lead
to sustained employment. It is also important to ensure that consumers are aware of
relevant policies and their effects on benefits and drawbacks so that they can make
informed decisions.
For people with mental illness to engage in actions aimed at getting and keep-
ing jobs, they need to believe not only that the benefits of working exceed the draw-
backs but also that the actions required are within their capabilities, will not cause
undue hardship, and have a reasonable chance of success. Additional research is
needed into the actions and strategies that people with mental illness consider and
use in moving toward employment. The importance of individuals’ actions and the
relationship of these to their outcomes have been largely ignored in previous
research, and this gap in knowledge needs to be addressed. Research to discover
which people with mental illness engage in what actions, under what circum-
stances, and with what consequences will bring us closer to understanding and pre-
dicting the actions and outcomes of people with mental illness with regard to
394 QUALITATIVE HEALTH RESEARCH / March 2004

employment. This might be important in designing policies and services to facili-

tate employment for people with mental illness.
Finally, the potential relevance of this theory to other populations is an area for
further study. Perhaps people with other types of disabilities, such as physical, in-
tellectual, or perceptual disabilities, engage in a similar process with regard to
weighing up benefits and drawbacks of employment. It is equally possible that the
theory could be modified and extended to help explain the employment-related
actions and experiences of the general population. Research to examine these pos-
sibilities would add to the understanding of the experiences of people with mental
illness by helping to illuminate the similarities and differences between their expe-
riences and those of other people.

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Anne Honey Ph.D., B.App.Sc.(Hons) O.T., B.Ec., is a senior research fellow in the School of Educa-
tion, University of Western Sydney, Australia.

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