Tuesday, 9 August 2011

Does Mental Illness Preclude a Career in the Caring Professions?

A history of mental illness can certainly impact on people’s future life and work prospects, even if a person makes a full recovery. One consequence of a history of mental illness can be to affect your ability to live and work in certain foreign countries. I have often heard it said that if you have ever been detained under the Mental Health Act, then the USA will not allow you a visa. This is, however, not strictly speaking the case. The regulations actually state only that someone is not eligible to travel under the ESTA visa waiver arrangements if:

“(b) you currently have a physical or mental disorder and a history of behavior associated with the disorder that may pose or has posed a threat to your property, safety or welfare or that of others; or
(c) You had a physical or mental disorder and a history of behavior associated with the disorder that has posed a threat to your property, safety or welfare or that of others and the behavior is likely to recur or lead to other harmful behavior.”

There appears to be no impediment for someone with a history of mental illness who is in remission or controlled by medication, and the restrictions only apply where there has been, or is likely to be a recurrence of risky or dangerous behaviour.

In the UK, there is a raft of legislation that is designed to explicitly protect people from the effects of discrimination. In addition to the Human Rights Act 1998, Article 14 of which prohibits discrimination on grounds including disability, there are also the Disability Discrimination Acts of 1995 and 2005, and most recently the Equality Act 2010. The effect of this legislation is to protect people from discrimination for a wide variety of reasons. These include discrimination on grounds of age, religion, sex, race, sexual orientation, and disability.

The Equality Act 2010 makes it unlawful for an employer “to discriminate against or harass a disabled person.” An employer is also required to make reasonable adjustments to accommodate disabled people within the workplace. Interestingly, there is also protection for people “who are associated with a disabled person or who are wrongly perceived as disabled.”

A person with a disability is defined under the Equality Act as having “a physical or mental impairment”. That impairment must have “a substantial and long-term adverse effect on their ability to perform normal day-to-day activities”. Guidance to the Act suggests a wide range of mental health conditions and mental illnesses would be covered by this legislation, including: “depression, schizophrenia, eating disorders, bipolar affective disorders, obsessive compulsive disorders, as well as personality disorders and some self-harming behaviour”.

There is also an interesting list of conditions which would not be considered to qualify as a disability. These include: “fear of significant heights, underestimating the risk associated with dangerous hobbies, such as mountain climbing, or a person consciously taking a higher than normal risk on their own initiative, such as persistently crossing a road when the signals are adverse, or driving fast on highways for own pleasure.” Which seems to exempt the presenters of Top Gear from protection under this legislation.

It has happily been my experience that Public Sector employers in particular take their responsibilities in relation to people with disabilities seriously. I have encountered a number of people with a range of mental health problems who have successfully trained for and obtained jobs in social work or allied professions. There follow a few brief histories.

Joni was a woman in her 30’s whom I worked with intermittently over quite a few years. I first saw her when she was referred to the CMHT with a history of severe bulimic behaviour. Over a period of months, I helped her work through the issues from her past that had led her to have such problems with her self image. These included a father who was never able to give praise for achievements. On one occasion as a teenager she had obtained a distinction in a musical instrument examination with an overall score of 93%. Her father looked carefully at the certificate and then said: “If only you’d worked a little harder, you could have got 100%.”

Over time, she recovered and was discharged. Several years later, she was referred again. In the intervening time she had trained as a social worker and was actually in employment in an older people’s team in the same local authority that employed me. Then she had become pregnant, had gone on maternity leave, had her baby, returned to work – then the issues with self image and self esteem kicked in again. Her only way of managing this was to return to her bulimic behaviours, with the addition of liberal quantities of alcohol: “An open bottle is an empty bottle.”

This time, talking therapy did not work. She became more despairing and desperate, her drinking and binge eating became increasingly out of her control, and one afternoon, when I discovered her about to take all her medication, I arranged for her informal admission to Bluebell ward in Charwood Hospital.

Once she was there, she changed her mind about the admission. She was detained under Sec.5(2) and a request was made for her to be detained under Sec.2 MHA. Because of my close involvement in her treatment on a voluntary basis, as well as the fact that she was essentially a work colleague, I arranged for a social worker with no association with her to undertake the assessment, and she was detained under Sec.2.

She remained in hospital for several weeks. Her mood improved. She acknowledged that she had an alcohol problem. She agreed to take antabuse as a means of controlling her alcohol consumption. It was agreed to give her a trial dose. As a routine measure, she was breathalysed immediately before. She tested positive as over the limit. She was still drinking, even on the ward, even as she was about to start antabuse.
A specialist alcohol treatment centre was sourced, and she agreed to go there. This involved residential stays as well as outpatient appointments over many months. As the centre undertook complete care management, I did not see her again.

But a year or so later, I heard that she was working, as a social worker, for the neighbouring local authority.

Joan was 20 years old. She was two years through a course training to be an occupational therapist when she made a very serious attempt to kill herself. She had cut her wrists as well as mutilating her body with a knife, and nearly died before she was found by her flat mate. She spent a couple of months in hospital, which meant that she had missed too much of her final year to catch up.

I liaised with the college. She had been a good student, and they were keen for her to complete the course, providing her mental health was good enough. As her care coordinator, I worked with her through her recovery from depression. We also worked on the issues from her earlier life that had led to this extreme act. She responded well to treatment. By the end of the academic year I was able to reassure her tutor that Joan was well enough to be able to retake her final year. As this was in another part of the country, I did not have any further professional involvement with her, although I did hear that she had passed her course.

A couple of years later I happened to be visiting a psychiatric hospital in a neighbouring county, and was taken by a colleague to the staff canteen. Joan was there. She had a job as a psychiatric OT.

John was working as a qualified social worker in a voluntary agency working with young people leaving care when he had his first episode of bipolar affective disorder. I first met him while he was an inpatient. He had been on a short term contract, and it had ended. He was very despondent, because he believed that, with a diagnosis of bipolar affective disorder, he would never get another job as a social worker again.

I tried to reassure him. I talked to him about the legal requirement on prospective employers not to discriminate on the grounds of his mental illness. I gave him some case histories. I encouraged him to come clean on his applications about his medical history when the time came, but to point out that these experiences could enhance his practice as a social worker. The session appeared to go well, and he left in a more positive frame of mind.

So what was the outcome for John? Well, not all my stories have sad endings. John did get a job as a social worker in a local authority. And to the best of my knowledge, he is still in employment, despite, or possibly even because of, his bipolar affective disorder.


  1. Thank you for this post. I am a 19 year old OT student who has a mental illness- I've ended up in the Emergency Department a few times and have had two psych ward admissions. It's good to hear there ARE people who succeed in a mental health job despite their illness. Its especially good for me to read of Joan's story.

  2. I can't think of a better grounding in empathy and humility than having been a user of the services you work in or of closely allied personal social services. I've worked alongside some advocacy staff who are past and present users of mental health services and also alongside AMHP / former ASWs who've suffered mental illness and formerly been psychiatic in-patients. These were not colleagues who flaunted their 'survivor' status but for whom their own experiences of distress and assistance clearly informed their practice.

    For me, the least effective practitioners are always the ones who think the service users are 'them' and don't appear to toy much with the idea that there might also be a 'we' or 'us' and that anyone could experience life-changing symptoms.

    In view of the horrible pressure staff work under in many personal social services and health settings, staff may be statistically likelier to have a brush with the mental health system on their own account: sadly, as employing organisations, health and social care organisations are remiss if not reckless in failing to promote mentally healthy work settings.

  3. Unfortunately this encouraging post doesn't fit with my experience - I know someone who was turned down for midwifery training because she had taken anti-depressants several years before.

  4. I think many of us have faced distress of some kind that contributed to our career choices, and that these kinds of lived experiences can be incredibly useful in the work (the wounded healer metaphor). However - and it's a big however - I also think it's important to have done our own work and healing so as to keep our own issues from interfering with client care.

  5. Where I work in Canada, most agencies actively solicit for and encourage applicants with "lived experience". My agency in particular has had peer support workers in various programs, but has now decided that peer workers should be integrated into the agency in various postions, and not only relegated to those postitions based on their consumer/survivor status. I think it's definately the right way to go!

  6. maybe my dreams of becoming a paramedic aren't totally futile. Perhaps i should stick with it after all.