Introduction Work status is a routine clinical indicator of functioning in mental illness, yet what “work” means varies dramatically across contexts. Personal Recovery Surviving and thriving amidst life challenges is a fundamental part of the human experience. In the context of “mental illness,” it is called “personal recovery.”1 Many persons with mental illness (referred to as “person” from hereon) manage “personal recovery” well and learn valuable life lessons. Clinicians focus on diagnosis and symptom recovery and don’t, or rather can’t, afford to spend time on aspects that the person and family are managing on their own. The clinician may not fully appreciate how they have adapted to unique challenges. Social Clock Theory The onset of mental illness can delay multiple culturally determined timelines: education, job, and marriage. For example, a person who couldn’t appear for exams due to a manic episode has to wait another year while their classmates have become seniors. A person with engineering degree arrears may not be selected for a campus interview, which could affect their immediate job prospects and future career trajectory. The person who is still studying can feel demoralized when the younger sibling who is earning a living gets married. Longer delays in the social clock may make educational, occupational, and social re-entry difficult.2 Rehabilitation Readiness It comprises 5 domains: need, commitment, self-awareness, environmental awareness, and personal closeness.3 The person should be “rehabilitation ready” for any psychosocial intervention to work. The Rehabilitation Referral The person whose symptoms are under control but who is unable to move toward meaningful functional goals or make use of opportunities is likely to be referred to psychiatric rehabilitation. A common reason for referral is “vocational rehabilitation.” Vocational Rehabilitation: Can we use a More Specific Term? “Vocational rehabilitation” can mean anything from simple engagement to competitive employment. Using a specific term will help communicate our understanding to the person, family, and professional colleagues. Vocation versus Work versus Job versus Employment Vocation is a deeply personal calling centered on purpose. Income and social recognition do not matter. For example, a person may earn a livelihood as a software engineer, but dancing may be a vocation. Work can be any activity. It can be personal, for family, or for others. It can be paid or unpaid. For example, helping with household chores, studying, working on the farm, feeding domestic animals, caring for a family member, creating decorative floor art (also known as “Rangoli” or “Kolam” in different parts of the country), and organizing a local event. This is a key domain in the Indian Disability Evaluation and Assessment Scale gazetted to assess disability due to mental illness.4 When a person is paid remuneration for work, it is called a job. Employment is the status of having a job. Understand What the Person and Family Have in Mind When a person and family present with complaints, the clinician’s expertise lies in identifying and labeling psychopathology. The same process applies to interpreting the person/family’s desire for improvement in real-world functioning. The person and family may express this in different ways, for example: A colloquial term (this varies by language Hindi-काम, Kannada-ಕೆಲಸ, Tamil-வேலை) which can mean any of the following: want the person to leave their house for socialization, have a daily routine, do something productive, just be busy, or earn money A metaphor: For example, “Standing on one’s own legs” to indicate that the person should own up to their responsibilities, be independent, and move on in life. Sometimes, the colloquial term may be used as a metaphor that the person should handle responsibilities like anyone employed. In our clinical experience, there are differences between the colloquial term/metaphor used by the person/family, their aspirations, and the ground reality. Make Sense of the Situation Each person and family situation is unique and must be understood within their socioeconomic context and life trajectory. Understanding this is time-consuming and a lot more complex than establishing an International Classification of Diseases/Diagnostic and Statistical Manual of Mental Disorders diagnosis that guides subsequent management. The clinician needs to understand the situation, what has been tried so far, and what is possible, to guide them further. Understand the Context of “Vocational Rehabilitation” Referrals The following case vignettes will help understand the complex reality. A 37-year-old female, 12th pass, on treatment for schizophrenia with prominent primary negative symptoms, was accompanied by her widowed mother, who works as a maid in nearby houses. During exploration, the mother is aware that her daughter needs care. Mother has tried her best to help her daughter earn a livelihood and has given up. Mother hopes that, with prompts, her daughter will brush her teeth, take a bath, change clothes, take medicines, and help with simple chores at home. She will take care of her daughter till she is alive, but doesn’t know what will happen subsequently A 31-year-old male, B. Tech Graduate, diagnosed with schizophrenia, whose symptoms are remitted on treatment, was accompanied by his parents from a higher socioeconomic status. During the exploration, parents stated that their son wasn’t listening to them and wasn’t taking on life responsibilities. They couldn’t arrange a marriage due to his “unemployed status.” Once he is employed, they can get him married and hope to see grandchildren. They have enough assets for the next generation A 28-year-old female who had worked for an Multi-national corporation information technology (MNC IT) firm is admitted for inpatient management of a manic episode. During the manic episode, which wasn’t properly recognized, she was terminated from her job for disciplinary reasons. She had an otherwise good track record. She was referred after clinical remission to help her secure another well-paying IT job. She hasn’t thought about disclosing her mental illness to her former or future employers A 50-year-old male, M.A. graduate, on treatment for schizophrenia, was accompanied by his widowed father, who sustains on a meager pension. He has never worked in his life and isn’t on good terms with his brother and sister-in-law. The father fears who will take care of his son after his lifetime. The person is aware of the situation but is not bothered. On exploration, the father has residential property that generates rental income, enabling the son to live comfortably A 43-year-old female, B.Com graduate, whose symptoms are controlled on medications, is in a residential rehabilitation facility, as there is no other living family member. She has no stigmata of mental illness. She is well-groomed, cares for other residents, and helps the clinical and office staff. She does not want to depend on the facility and wants a job to support herself financially. She has not adhered to prescribed medications in the past. Interpret Evidence-based Practice for the Clinic Population In supported employment (especially the “Individual Placement and Support” model), the person is guided to choose their desired job in the community and work towards getting it.5 From the lens of rehabilitation readiness, the “time-and resource-intensive process” engages the person, tests their commitment, and can enhance self-and environmental awareness, helping them move on in life. Published studies don’t account, assess, report, or discuss contextual factors that influence employment. Such factors include personal recovery, social clock, and rehabilitation readiness. The study participants differ from the typical clinic population in their acceptance of the illness identity and prior engagement in rehabilitation services. Most evidence comes from high-income countries, with different social, economic, and cultural contexts that cannot be extrapolated to India.6 In India, families facilitate work opportunities based on a person’s ability, interest, and willingness.7-9 The family may negotiate “below-market rate” wages for informal jobs that employ the majority. In the formal sector, such an arrangement is interpreted as exploitative and is legally punishable. In some high-income countries, disability pensions are as high as the minimum wage, which can deter people from working. Right to Work versus Right to Job While Article 19(1)(g) guarantees the fundamental right to practice any profession or carry on any occupation, trade, or business in any part of the country, the Indian Constitution does not guarantee a job as an enforceable entitlement.10 Being engaged in some work with a nominal incentive cannot be compared with earning a livelihood to support one’s own family. Employment is an achieved social status. While suitable opportunities can be facilitated, capitalizing on and sustaining them depends on the person. Unlike clinic-based biological and psychological interventions, a social intervention such as “supported employment” is a marathon in the community.11 Leadership is required to nurture a network of stakeholders (including employers) over the years through shared values, mutual trust, and respect. Sustaining this relationship requires referring a suitable person, not someone based on sympathy. Conclusion In a diverse country like India, it is not feasible for a clinician to be aware of all livelihood options. The clinician should understand what the person and their family mean by “work” and guide them to avail suitable local opportunities. Referral to another setting should be considered only if the person appears motivated and the family has the resources to sustain the process in the long term.
Sivakumar et al. (Wed,) studied this question.