MentalHealthandUnemploymentinScotlandUnderstandingtheimpactofwelfarereformsinScotlandfor

individualswithmentalhealthconditions

AreportbasedonresearchfundedbyTheCarnegieTrustforthe

UniversitiesofScotland

ProfessorAbigailMarksandDrSueCowanCentreforResearchonWorkandWellbeing(CRoWW)

Heriot-WattUniversity

DrGavinMaclean

EmploymentResearchInstitute(ERI)

EdinburghNapierUniversity

February2017

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AcknowledgementsWewouldliketothankalltheparticipants,whogavesogenerouslyoftheirtimetosharetheir views and experienceswith us.Wewould also like to thank The Carnegie Trust forfunding the research andMrGordon Jack for assistingwith the dissemination event andformattingofthisreport.

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GlossaryDLA DisabilityLivingAllowanceDWP DepartmentforWorkandPensionsESA EmploymentandSupportAllowanceHMRC HerMajesty’sRevenueandCustomsJSA Jobseeker’sAllowanceMHC MentalHealthConditionPIP PersonalIndependencePaymentUC UniversalCreditWCA WorkCapabilityAssessmentWP WorkProgrammeWRAG Work-relatedActivityGroup

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ExecutiveSummary

During2016,30individualswithamentalhealthcondition(whoclaimedESA,havehadtheirESAwithdrawnandmovedontoJSA,orhavebeendirectedintotheWRAGgroupbasedonthedecisionoftheWCA)wereinterviewed.The30participantswererecruitedthroughout Scotland. In addition, we interviewed seven individuals who hadinvolvement with various intermediaries, such as advocacy organisations, collectiveadvocacygroups,CitizensAdviceBureauand(anexemployeeof)Ingeus.Participantswererecruitedthroughadvocacyorganisations,voluntarygroupsandthelocalmedia.Overall,weestablishedthat theWorkCapabilityAssessment (WCA)doesnot inspireconfidenceinparticipantsinitsadequacyforassessingmentalhealthproblems.Thereisconcern that theassessorsdonotappear tohaveappropriateexpertise inmentalhealth.TheWCAexperienceformany,causedadeteriorationinpeople’smentalhealthwhichindividualsdidnotrecoverfrom.Intheworstcases,theWCAexperienceledtothoughtsof suicide. People felt that that therewas an inconsistency in termsofGPrecommendations and the WCA recommendations. Many people were subject tofurtherupsetanddistressduetocommunicationfromtheDWPbeinglostinthepost.Having amental health condition (MHC) in parallel with being unemployed and onbenefitsleadsindividualstobeconfrontedwithmultipleandcompetingstigmas,whichtheyfindhardtomanageandthesebecomeself-reinforcingandself-perpetuating.TheWCAandothermandatorystructures,workagainstindividualsdevelopingorretainingemployability skills as voluntary work is seen as demonstrating fitness for work;educationisalsonotpossiblewhilstreceivingESA.Thesystemfailstorecognisethatformany,volunteeringisgoodforwellbeingandmaybe‘asgoodasitgets’.Whilst the Scottish Government does not have control over the ESA component ofUniversalCredit,itneedstocarefullyconsiderhowanybenefitsthatisdoeshavecontrolover(e.g.DLA)areassessedandmanagedforpeoplewithaMHC.Moreover,ascontrolovertheWorkProgrammeandWorkChoiceistobedevolvedtoScotland,theScottishGovernmentshoulddevelopreplacementprogrammeswhichareappropriatetopeoplewithmentalhealthproblemswhichcanalsoworkinparallelwiththebenefitssystem.

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1. IntroductionThissectiondescribesthebackgroundtothestudyandsetsoutitsaimsandobjectives.

1.1Background

In June 2011, the then Coalition Government introduced a single welfare-to-workinitiative,theWorkProgramme(WP;DWP,2015).Underthisinitiative,individualswithadditionalneedssuchaschronicphysical illnessormentalhealthconditions(MHCs),whowereinreceiptofEmploymentandSupportAllowance(ESA)orincapacitybenefits,were reassessed in terms of their ‘fitness to work’. These reassessments wereundertaken using the Work Capability Assessment (WCA), which is designed tocomprehensivelyassessindividual,work-relatedfunctionality.

TheWCAiscontractedouttoprivatesectororganisations(previouslyAtosHealthcare,butcurrentlyMaximus).Itisconductedby‘assessors’.Theseassessorsarehealthcareprofessionals,e.g.nurses,occupationaltherapists,physiotherapists,whoforwardtheirrecommendation to the Department for Work and Pensions (DWP), with the finaljudgementmadebyaDWPemployee.

TheWCAhasthreepotentialoutcomes:

1. Claimantsareassessedasfitforwork.TheseclaimantsarenotentitledtoESA,butcanclaimJobseeker’sAllowance(JSA).

2. The claimant is placed in the Work-related Activity Group (WRAG). Theseclaimants are paid ESA and expected to engage in activities to prepare foremployment, such as work-focused interviews with employment advisers,voluntarywork,worktrials,ortraining.

3. Claimantswhoareassessedasunabletoengageinwork-relatedactivitiesareplaced in the Support Group. These claimants are not required to engage inactivitiestoprepareforemployment,butmaydoso,iftheywish.TheyarepaidahigherrateofESAthanclaimantsintheWRAG.

TheWCA independent review teamreported that20percentof claimantsassessedbetween2010and2012wereallocatedtotheSupportGroup,withoutbeingrequiredto undergo theWCA. Of the remaining 80 per cent of claimants, 42 per centwereassessedasfitforwork,and23percentwereplacedintheSupportGroup(Litchfield,2013).Asof theendofMay2016 (the latestdate forwhich theNationalStatistic isavailable) 2.47million peoplewere receiving ESA (DWP, 2017). People withmentalhealthissuesconstitute40%ofthosewhoundergoaWCA(DWP,2015).

Sinceitsimplementation,nearly140,000individualswithmentalhealthandbehaviouraldisorders have participated in the WP (DWP, 2015). People with mental healthproblemsaremorelikelytobesanctioned1,thanthosewithout,becauseoftheirlackof

1Havetheirbenefitscutorwithdrawn

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engagementwiththeWP.Sixoutofeverytenpeoplewhohavebeensanctionedhaveamentalhealthproblemorlearningdisability(SmithCommission,2014).

The impact of MHCs on an individual’s functioning can fluctuate considerably. Forexample,anindividualwithananxiety-relatedconditioncanfinditdifficulttoleavetheirhome on some days, while they might find it impossible to leave on others. Thus,sanctioningcanbeconsideredtobediscriminatory(SAMH,2014).

OfthelargenumberofindividualswithMHCswhohaveparticipatedintheWP,only7,060 have sustained jobs (DWP, 2015). People with MHCs often experiencediscriminationbyemployers,andsofinditmoredifficulttofindemployment(SAMH,2014). Thosewho domanage to findwork are often stigmatised by employers andcolleagues,withlittleornoorganisationalstructurestosupportthem(Marks,Richardsand Loretto, 2012). These problems can be compounded by self-stigmatisation, aprocessbywhichpeoplewithmentalhealthproblemswhoareawareof,orsubjectedto, negative public attitudes (or negative experiences of job seeking) begin to applythemtothemselves.Self-stigmatisationhasanegativeimpactonhope,empowermentandself-esteem-threeelementsthathavebeenfoundtobepositivelyassociatedwithmentalhealth recovery (e.g.StickleyandWright,2011)and is likely to impactonanindividual’sabilitytoseekandretainwork(Warneretal.,1989).

Whilesomearguethatworkhelpsmentalhealthrecovery(e.g.WaddellandBurton,2006)recentresearchhasshownthatindividualswithmentalhealthproblemswhoareinwork,oftensuffer,duetostigmatisationbyemployersandcolleaguesandfrequentlyweakorganisational structures to leading to failure to support suchworkers (Marks,RichardsandLoretto,2012).

ScotlandwillhavelimitedcontroloverthenewlyintroducedUniversalCredit(UC)whichis comprised of all existing benefits. However, Scotlandwill have some influence intermsofdiscretionarytop-uparrangements.Moreover,therewillbethedevolutionofdisability, industrial injuries and carer’s benefits,many ofwhich affect those absentfromworkduetomentalhealthproblems. Thenewlydevolvedpowers,whichwereagreedunder theScotlandAct,willalsoallowScottishministers todesign theirownemploymentservicesfordisabledpeopleandthoseatriskoflong-termunemploymentforthefirsttimefromApril2017,andwillaccountforaround£2.7bnor15%ofthetotalScottishbenefitsbill.AfullScottishprogrammeofemploymentsupportbeginsinApril2018.

1.2ResearchAimsandQuestions:

Theoverarchingaimofthestudy,wastoexaminetheexperiencesofindividualswithmental health problems of the job-seeking process, and benefits assessment, inScotland.

Thefollowingresearchquestionsguidedthestudy

• Whatare theexperiencesofpeoplewithmentalhealthproblems in theirattempt(s)to(re)enteremployment?

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• Whatistheimpactofthejobsearchandjobsearchoutcomesonindividuals’socialidentity?

• Whatistheimpactofthejobsearchandjobsearchoutcomesonindividuals’wellbeing?

• HowdoestheWCAimpactonindividuals?• What are the opportunities for the Scottish Government to improve the

experiences and outcomes of benefits assessment and return to workprocessforindividualswithmentalhealthconditions?

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2. MethodsThissectiondescribesthemethodsusedinthestudy.2.1Participants TheonlyinclusioncriteriaforparticipantswereamentalhealthconditionandthattheyclaimedESA,havehadtheirESAwithdrawnandmovedontoJSA,orhavebeendirectedinto theWRAG group based on the decision of theWCA. A number ofmethods ofrecruitmentwereusedinordertoensuretheinclusionofparticipantswitharangeofmentalhealthproblemsandexperiencesofjob-seekingandthewelfaresystem.TheseincludedadvertisementsplacedinTheMetroandontheDailyRecordwebsite.Callsforparticipantswere also disseminated throughmental health service user groups andadvocacygroups.ThefinalgroupofparticipantswithMHCscomprisedthirtyindividuals;twentymenandtenwomen.Allbut threedisclosed thenatureof theirmentalhealthproblems.Themajority suffered fromanxiety and/ordepression,which is not surprising given thatthesearethemostcommonmentalhealthproblems.Aminorityhadbipolardisorder,other forms of psychotic disorder, obsessive compulsive disorder and borderlinepersonalitydisorder.Fourparticipantshadneverworked.Participants,whodisclosedtheirage,rangedfromtheir30stoearly60s.Duringtheirinterviews,anumberofparticipantstoldusthattheyhadneededsupportto negotiate the welfare system and, in some cases, appeal their WCA decision.Accordingly, interviewswereconductedwithfourmentalhealthadvocacyworkers,aCitizen’sAdviceBureauworker,andaformerIngeusemployee.Thepurposeoftheseinterviewswas to gain insight into what they considered to be the constraints andbenefitsofthecurrentsystemonthebasisoftheirexperiencesofsupportingclaimantswithmentalhealthproblems.FurtherdetailsofparticipantscanbefoundinTablesOneandTwo.

Name Occupation MentalHealthConditionAlvin Routine AnxietyAndrea Routine Anxiety,Depression,OCD,BPDBryan Intermediate DepressionDavid Routine DepressionDonna Lowermanagerial,administrative&professional BipolarHelena Intermediate Anxiety,DepressionHenry Neverworked&long-termunemployed Anxiety,PsychosisIain Lowermanagerial,administrative&professional Anxiety,DepressionJames Lowermanagerial,administrative&professional Anxiety,DepressionJeremy Semi-routine Depression

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Name RoleBarry AdvocacyWorkerAndrew AdvocacyWorkerFred AdvocacyWorkerLuke CollectiveAdvocacyWorkerJudith CABOfficerBrenda Ex-IngeusTableTwo:ResearchParticipants(Intermediaries)

Jessica Routine Depression,AnxietyJohn Lowermanagerial,administrative&professional Depression,AnxietyJulia Lowermanagerial,administrative&professional DepressionKen Intermediate Anxiety,PsychosisKevin Intermediate Anxiety,DepressionLiz Neverworked&long-termunemployed BorderlinePersonalityDisorderMaria Lowermanagerial,administrative&professional Anxiety,DepressionMark Neverworked&long-termunemployed DepressionMartin Semi-routine Anxiety,DepressionMatthew Semi-routine UndisclosedMegan Semi-routine Anxiety,DepressionPeter Semi-routine Anxiety,DepressionPhil Semi-routine DepressionRuby Lowermanagerial,administrative&professional Anxiety,DepressionRyan Neverworked&long-termunemployed Anxiety,DepressionSam Semi-routine UndisclosedSimon Semi-routine DepressionStephen Routine UndisclosedValerie Routine Anxiety,DepressionVaughan Intermediate Anxiety,DepressionTableOne:ResearchParticipantswithaMHC

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2.2DataCollectionInterviewswereconductedin2016inavarietyoflocationsacrossScotland.Participantschosewheretheywantedtobeinterviewed.

TheinterviewswithparticipantswithaMHCweresemi-structuredinnature,withthecontentbasedonatopicguideinformedbytheresearchaimandresearchquestions.Hence it covered participants’ experiences of the WCA and the Work Programme(whererelevant),theirattemptsto(re)enterthejobmarket,thetypesofjobsforwhichtheyhadapplied,andtheresponsesofpotentialemployers,aswellasanyexperiencesthey had had of employment and Jobcentre Plus. It also included the impact ofparticipants’experiencesontheireconomic,socialandpsychologicalwellbeing.

Eachinterviewbeganwithanopeningquestionwherebyparticipantswereinvitedtotellusabouttheirworkandmentalhealthhistoryfromthetimetheyleftschool,untilthe present time. Thereafter, there were no set questions that were asked of allparticipants.Mostareasofinterestincludedinourtopicschedulewereaddressedbyparticipants,withtheaidof interviewerprompts, inthecourseofrespondingtoourinitial question. Where topics were not addressed spontaneously by participants,additionalquestionsrelatingtothetopicofinterestwereasked.

Interviewswere,therefore,conductedinarelativelyinformalmannerandtooktheformofaneverydayconversation,withtheemphasisoneachparticipant’sperspectivesandexperiences.

Oncompletionoftheirinterview,participantswithaMHCwerecompensatedfortheirtimewitha£20 supermarketvoucher.Travelexpenseswerealso reimbursedwhereappropriate.

2.3AnalysisData were analysed using ‘template analysis’ (King, 2004), a method informed bygroundedtheory.However,incontrasttogroundedtheory,templateanalysisallowsforthedevelopmentofcategoriesandthemespriortodatacollectionbasedonthetopicguide.Thecreationofthis‘template’allowsforthedatatobe‘sorted’accordingtotheaprioricategoriesandthemes,andfornewcodesandthemestoemergeastheanalysisproceedsthroughtheuseofconstantcomparisonofemergingcategoriesandthemes,withinandacrosstranscripts.Thefinalthemeswerethenusedasthebasisforselectingtextthatcouldserveasexemplars.

TheanalysiswasaidedbytheuseofNVivo10,aqualitativeanalysissoftwarepackage.

2.4Ethicalissues

Ethical approval for the study was given by Heriot-Watt University School ofManagementandLanguagesEthicsCommittee.

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Individuals who answered one of our calls for participants were given a phonenumber/emailaddresstocontactoneoftheresearchersfromwhomtheycouldreceivefurtherinformationaboutthepurposeofthestudyandwhatitwouldentail.Thereafter,iftheydecidedtoattendforinterview,theywereprovidedwithfurtherdetailsabouttheinterviewprocess.Theywerealsogivenanopportunitytoaskanyquestionstheyhadaboutthestudybeforefinallydecidingwhethertheywishedtoparticipate.Thosewho decided to participate were asked to sign a consent form. Participants wereinformedthattheycouldwithdrawfromthestudy,andwithdrawconsentfortheuseofanydatacollected,withouttheneedtogiveareason.

Itwasrecognisedthatsomeparticipantsmightfindtalkingabouttheirexperiencesofmentalhealthproblems,unemployment,andtheirattemptsto(re)enterthejobmarketupsetting.Interviewswereterminatedifparticipantsbecamedistressed.Inaddition,allparticipantswereprovidedwithcontactdetailsforBreathingSpaceandtheSamaritans,incasetheyfelttheyneededfurthersupportpost-interview.

Alldatawerestoredsecurelyinaccordancewithdataprotectionlegislation.Allnamesand identifying information have been changed to protect the anonymity ofparticipants.

2.5Structureoftheremainderofthereport

Sections1and2havefocusedonthebackgroundtostudyandthemethodsemployed,respectively.Inthefollowingthreesections,weconsiderthefindingsofthestudy.InSection6,wepresenttheconclusionsand,basedonthese,makerecommendationsforpolicyandpractice.

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3. ExperiencesoftheWorkCapabilityAssessment3.1Introduction

Inthissection,wereporttheparticipants’responsestotheWCA.Theaimofthissectionis to illustrate the experiences of theWCA from the point of view of the researchparticipants.Thissectionwillbeginbysummarisingtheexperienceoftheassessmentitself. The following sections will highlight the difficulties individuals with a mentalhealthconditionhaveinreceivinganaccurateassessmentoftheirillnessviatheWCA.Wewillthenfocusontheappealsprocess.

3.2FitnessforpurposeoftheWorkCapabilityAssessment

TheWCAisatwostageprocess.Thefirsttenquestionsaskedduringtheassessmentdeterminewhetherornotanindividual isfitforwork.Shouldanindividualreceiveascoreoffewerthan15points,theindividualisdeemed‘fitforwork’.ThesecondstagedetermineswhethertheindividualistobeplacedintheWork-relatedActivitiesGroup(WRAG)ortheSupportGroup.

Noneoftheparticipantsfeltthatthefirststagequestionsweresuitedtoassessingtheircapabilitytowork.AsJamesexplained:

“So18minutesittook,andallshewasinterestedinwasthebogstandard“Canyouwash, can you cook, can you do this, can you do that?” And as far as shewasconcerned,asfarastheassessmentwasconcerned,ifIcoulddoanyofthesethings,Icouldtiemyownshoelaces,washmyhair,thatmeantIwasfitforwork”(James)

The first ten questions tend to focus on the claimant’s ability to undertake routinephysicaltasks.Hence,theWCAquestionscentreonthepotentialphysical limitationsthatanindividualmayencounter,ratherthananylimitationstheymightfaceasaresultof their mental health problems.Moreover, by their very nature, the symptoms ofmental health conditions can be intermittent and fluctuate over time. Thus the‘snapshot’ of the claimant’s condition captured during the WCA may not berepresentativeofthelimitationsthattheindividualmightfaceonaday-to-daybasis,andhencetheircapabilitytowork.

“So they’re just judgingyouon that45-minute interview, so if you’re reasonablywellthatday,theysayyou’refitforwork.Butyouknow,theweekbeforeyoucouldhavebeenlyinginbedalldayorwhateverortheweekafter.Soit’snotreallyfairtojudgeyouonthat”(Peter)

“I think that’s the reason I failed was because their criteria weren’t capable ofdescribingwhatIwasactuallysufferingfromandthat’swhyIthinkIfailedthefirstone. So, Iwas answering honestly but she justwasn’t asking the questions thatproperlybroughtoutthesymptomsthatIwassuffering”(Phil)

3.3Lackofconfidenceinassessors

Participantsreportedawiderangeofhealthcareprofessionalswhoactedasassessorsfor the WCAs. The majority of participants believed that their assessors were not

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qualified or trained to be able to assess mental health conditions. Paediatricians,physiotherapistsandadoctor(whohadallegedlybeendismissedbytheNHSforgrossmisconduct)werethebackgroundsofjustsomeofthepeoplewhohadrunparticipants’assessments.

“Irememberoneofthemclearly,hewasaGermandoctorbutIcouldn’ttellyouifthatwasthefirstorthesecond.Ithinkhewasthesecondone.Thefirstone,Ithinkshe may have been… I think she was a physiotherapist, actually; dophysiotherapists…Iknowitdefinitelywasn’tafullyqualifieddoctor,itmighthavebeen a nurse practitioner. They didn’t seem to knowmuch aboutmental healthanyway”(Phil)

Various exampleswere given by participants of attempts to override the assessor’srecommendationbytheirownhealthcareprofessionals,whowereseentobebetterqualified/placedtomakeajudgement.Forexample,Brian,whowasassessedasbeing‘fitforwork’,askedhisoccupationaltherapisttointervene:

“Igotzeropoints[intheWCA],soIgotmyoccupationaltherapisttowritealetterwhichwassenttothem…basicallysaying,heshouldstayandthisiswhy“becausewe’redoingworkwithhimandyou’reactuallyjeopardisingtheworkwe’redoingwithhimaspartofhisstagedrecoveryifyouputhimonJSA”(Brian)

3.4MistrustoftheWCA

Many participants expressed theirmistrust of the assessment process. In particular,therewasastrongsensethatnomatterwhattheydidorsaid,itwassimplynotpossibleforthemto‘getitright’,andthereforegetafairassessmentoftheirworkcapabilityandtheirwelfareneeds.Forexample,DonnawentforherWCAjustafterbeingdischargedfromhospital.Sheattendedasifshewasattendinganyotherinterview,andtriedtolookherbest.Likemanyoftheparticipants,appearingwellandona“goodday”resultedinazero-pointassessmentresult:

“BasicallyIgotaletterremindingme,itwasa12-minuteinterview.Imean,I’djustgotoutofthepsychiatrichospital,Iwasonmedication.Itseemstomesoobvious,Iwassonaïve,andIasked...Iwasdressedsmartlymyself,youknow,somepeoplereallyplay it thickonce they’vebeen inandouta few times,whichannoyedmebecause it gives a false indication of what it’s like. So this doctor… it’s aquestionnaire,20questions,basically.Again, thequestionsyou’reansweringareridiculously...juststupid.Imean,IjustansweredthemasIsawfit.Iwaszeropointsafter12minutesandIwassenthomewithalettertosayyoudon’tpass,basically”(Donna)

SimplyturningupforaWCAwasseenbysometobeaproblem:

“Imeanit’sridiculous,theytellyou,ifyouturnupfortheinterviewasfarasthey’reconcernedyou’rewell,butthenifyoudon’tturnupfortheinterviewyourbenefitsget stopped – so you’re damned if you do, damned if you don’t sort of thing”(Peter)

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Otherparticipants struggled to knowhow toanswer thequestions theywereaskedduring theWCA.While the questions asked of them during the assessment appearanodyne, when they were answered at face value, concerns were expressed thatparticipants’responsesprovidedmaterialforassessorsandtheDWPtodrawbroaderconclusionsabouttheclaimant’scapabilityforwork.Oneoftheadvocacyworkersweinterviewedroutinelyprovidedadvicetoclaimantsabouthowtodealwithapparentlystraightforwardquestionsaskedduring theWCA, inorder toensure that theirworkcapabilityandwelfareneedswerefairlyassessed:

“Soforexampletheywon’task“How’syourconcentration?”Theyaskquestionsthat will conclude you concentrate, for example, “Do you watch TV?” Andsomeonesays,“Yes,IwatchTVallthetime.”Thentheywillconcludethatyourconcentration’sfine.Theymightalsoconcludeyoumightnotbethatdepressedbecause you’re not showing that symptom of depression, which is lack ofconcentration. So I get people after they’ve already told me that theirconcentrationislow,andIsaytothemdoyouwatchTVwhichtheymightjustfortheassessment,Ikindoftrytoplugformoreasin“DoyoualwaysrememberwhathappensinTVprogrammes?Doyoueverfindittrickytopayattentiontowhat’sgoingon?”Stufflikethat.Sotheykindofcomeout,“Ohyes,Idon’treallywatchit”.Peoplesaythingslikethattome,intheassessmentwhenyou’rereallyanxiousandstressedyou’renotthinkingaboutgoingintospecificdetailsthatyoudon’tevenknowareimportantaboutthis”(Andrew,AdvocacyWorker)

Intermsoftheassessmentoftheirmentalhealthconditions,participantsconsistentlyfelt that their health was being misreported and misjudged. James explained thatfollowinghis“failed”WCA(getting less than15points),hereceivedthenotesofhisassessment.Theseindicatedthatduringhisassessmenthehadnotdisplayedphysicalsignsconsistentwithhismentalhealthdiagnosis.

“Duringthequestionandanswersessiononcetheyturnyoudownandyouappealtheysendyouall thepaperssoyouseeobservationsandcomments thatweremadebythepersonwhocarried itout.OnmyformItoldherthat…well I toldthem that I suffered from anxiety and panic attacks and she made twoobservationswhichwerequiteinteresting.Shemadeanobservationduringthis18minutesthatIwasnotrockinginmychairandherobservationwas…andit’swritteninblackandwhite,“Iwasnotrockinginmychair(whichisconsistentwithanxietyandpanicattacks)”.NowacoupleofpagesonfromthatobservationshemadeafurtherobservationthatIwastearfulthroughouttheassessment.NowIwas tearful throughout the assessment because I was having a panic attack.Obviously I raised that atmyappeal andwhen I raised that atmyappeal thedoctorwhowas onmy appeal panel he actually physically gasped andwent Icannotbelieveanyonehasthoughtthatletalonewrittenitdown”(James)

Formanyoftheparticipants,dealingwithbureaucracywasthemosttime-consumingandconfusingpartofthewelfareprocess.ClaimingESAcarriesthepresumptionthatyouarenot fit towork,but the requirement tobe reassessedor toundertakeworkrelatedactivities(ifthepointsscoredfallwithintheWRAGrange)meanthatmanyoftheparticipantsfeelasiftheyarenotgivenenoughspacebythesystemtorecover.Themajorityoftheparticipantsshareasuspicionoftheentireprocess.

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3.5AppealingtheresultoftheWCA

Mostoftheparticipantswhowereassessedas‘fitforwork’askedforthedecisiontobereconsidered. The majority of reconsiderations lead to the original decision to beoverturned.ThismustbecostingtheDWPanawfullotofmoney.

“Idoreconsiderationrequests,whichisthefirststagebeforetheappeal.Appealsarebasedonlegislation,sotheyreallyneedsomeonethat’s...,andadvocacyismoremakingsurethepersongetstosaywhattheywanttosay.They’renotgoingtoknowaboutlegislation,buttheyneedadviceforthat,sothey’rebettergettinganadviceworkertodothatforthem.Ihavebeeninvolvedinthereconsideration,havingtowriteareconsiderationandputoutallthepointsforwhytheyweren’tawarded.Ithinkintotal,oftheonesthatI’vedone,therewasonlyonethathadto have an appeal afterwards, so the Board had overturned it at thereconsiderationprocess”(Andrew,AdvocacyWorker)

“February 2012 was when I was assessed and then they turned me down. Iappealed,IwontheappealinJuly2012anditwasallbackdated,themoney,theextraallowancebitso Igotnearly… infact itmighthavebeen justover£1000actuallybackdated.Yes,Ithinkitwasjustover£1000.AndIwasreassessedagainin2013,and they turnedmedownagain,and Iappealed,and theappealwassuccessful,andthenIgotanotherbackdatedpaymentandthat’sbeeneversincethen”(James)

3.6Summary

Thissectionhaspresentedthefindings inrelationtoparticipants’experiencesoftheWCA.andnegotiatingthewelfaresystemafterafailedassessment.TheWCAquestionsseemtofocusonphysicalconstraintswhichmaynotalwaysseemrelevanttopeoplewith amental health condition. However,many of the participants in this researchfound that their mental health conditions limited their ability to undertake somephysicaltasks.Yet,theintermittentnatureofmanyoftheconditionsmeantthatwhilethe participants were able to report they could do the tasks at the time of theassessment.TheWCAdoesnottakeintoaccountthefluctuatingconditions.

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4. EmployabilityandWelfareReformWiththeputativeaimofwelfarereformbeingtoreduceclaimsfortheESAelementofUCandtomovemorepeopleintoemployment,thissectionevaluateshowsuccessfulthe system is, based on the experiences of the participants. Therewas a variety ofexperiencesfromindividualsintermsofearlierexperienceofemployment.Forsome,theirmentalhealthconditionhadbeenalife-longconcernandotherhadhadsuddenonset of mental ill health – having to stop working immediately, often leavingestablishedcareersbehind.As identifiedinTableOne,wespoketoawidevarietyofindividuals including lawyers, scaffolders, clerical workers etc. and only one of ourparticipantsmanagedtofindwork–agraduatewhodeliveredfreenewspapers.

4.1TheDesiretoWork

The vast majority of the participants wanted to work and when they felt able toarticulateavisionofthefutureitalmostalwaysinvolvedemployment.Theportrayalsoftheunemployedinthepopularmediaareveryclearlyatoddswiththeexperiencesofourparticipants.Manyofthepeoplewespoketohadbeenundertakingwork-basedactivities–eithervoluntaryworkorworkpreparationprogrammes.Forthemostpart,theseactivitieswereinitiatedbytheparticipantsthemselves.

Yet,formanyoftheparticipants,volunteeringrepresentedthe“thinendofthewedge”(David). WCA assessors and DWP advisors frequently viewed volunteering as ademonstrationofreadinessandfitnessforwork.Assessorsandadvisorswerefailingtounderstandthatvolunteeringandworkexperienceprogrammesprovided individualswithstructureandpurposebutalsoallowedflexibility,ensuringthat ‘work’couldbemanagedaroundfluctuationsinmentalhealth.

Moreover,asAndrew,oneoftheadvocacyworkersexplained,thereisnovalueplacedonvoluntaryworkandthatremovingbenefitsandmovingclaimantsontopaidfulltimeemploymentistheonlygoalofthesystem:

“Someofthepeoplewe’vespokentoweredoingvoluntarywork,doingvoluntaryworkquitehappily,thenhadtogofortheirassessmentandcouldn’tthengobackintovoluntarywork,andthereseemstobealsosomesortofstigmatisationaboutvoluntarywork.Maybeforalotofpeople,voluntaryworkisgoodforthem,andit’snotgoingtogetanybetterthanthat,butthere’snorecognitionthatactuallythatisacontribution”(Andrew,AdvocacyWorker)

Thevastmajorityofparticipantswhowerevolunteering,stoppedthisactivityaftertheirinitialWCA.Thereweremultiplereasonsforthis.Often,theprocessoftheWCAhadbeensotraumaticfor individualstheirmentalhealthhadbeenfurtherdamagedandtheywereunabletosustainanywork-relatedactivity.Aswestatedpreviously,inothercases,peoplefeltthattheirexperienceofvolunteeringhadbeenusedintheWCAasevidencethattheywerecapableoffullemployment.

Anumberofparticipantshadbeenoutofworkforsuchanextendedperiodoftimethatthey felt that re-training though a college coursewould be the only realway of re-

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enteringemployment.However,thereisnomechanismforundertakingqualification-basedcourseswhilstonESA(ortheESAcomponentofUC).Again,theassumptionbeingthat attendance at college indicates work readiness. The link between individuals’havingcontrolovertheirworkinputandmentalhealthisnotacknowledgedbytheDWPor WCP contractors. For some, training for employment may help improve mentalhealth.Forothers,voluntaryworkisacontributionthatismanageable–butthisisasclosetoworkastheyareevergoingtobe.

4.2“TheWRAG”

The ESAwork-related activity group (WRAG)members are in a different position tothoseintheESAsupportgroupastheyareexpectedtoattendwork-focusedinterviews,toundertakework-relatedactivitiessuchastrainingorconditionmanagementgroups.WRAGmembershowever, have a lower rateof benefit paymentbecause thework-relatedactivitycomponentisremuneratedatalowerratethanthesupportcomponent.There issupposedtobeaone-year limitonclaimingcontributoryESAfortheWRAGgroup.

WhilstwefoundoneparticipantwhowasinWRAGandhadhadnocontactwitheithertheDWPoraworkprogrammeprovider,therewasagreatdealofvariationintermsoftherequirementsof individuals in thegroup.Somewereexpectedto ‘check in’withJobcentrePlusevery fewmonths,whereasotherswereexpected toengage inmoreformalactivities.

“The supposed support they get in the Work-Related Activity Group isridiculouslypoor.Ihavepeoplethatbasically...whatthey’lldoisthey’llphonethem. They’re supposed to have a face-to-face interview every couple ofmonths,but they’llphonethemmaybeonceeverysixmonths.“Howareyoudoing?”“Oh,I’mstillnotdoingthatgreat.”“Okay,fine,I’llphoneyouinabit,”and that’s it.They just leave themalone,because theycan tick thebox thatthey’vehadcontactandthat’s it.There’snosupportabout“whatcanwebedoingtohelpthemhere?”It’skindoflike“you’vebeenplacedinthisgroup,butwedon’tthinkyoushouldbethereandthere’snothingwecandoaboutitthisyear.We’lljusttickthisboxandmoveon.”(Andrew,AdvocacyWorker)

Overall,ourresearchfoundagreatdealofinflexibilityintermsoftheactualactivitiesfortheWRAGparticipants.IndividualswithaMHChaveparticularconstraintsthatarenotaccommodatedbytheWRAGactivities.IllustrativeofthisisMaria,whosuffersfromanxietyinsocialsituations.Forherbeinginaroomwithpeopleandhavingtointeractwasacauseofexcessstress:

“You’refeelingreallydepressedorfeelingveryanxiousalotofthethingsthey’reaskingyoudo–it’smakingmefeelworse.Itsetsyoubackhavingtogototheseappointments.AndthenIhadtogoto,itwaslikeawork,apreparingforworksortofcoursething.Anditwasmeanttobeworkingwithpeoplewithhealthconditions.ButIfoundthatdifficultbecauseitwasanawfullotonthelimitedenergyIhad,anditwasalotofanxietyaswell.”(Maria)

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The image that we captured was that WRAG was not working for anyone. Manyindividualsseemedto feel trappedwith thesystem.Theendresult is thatmanytheparticipantsfeltimprisonedinWRAG.TheactivitiesputthemunderpressurewhereasbeingignoredledtoafearthattheyshouldhavebeenmoreactiveandthatalackofactivitywouldeithermakethemineligibleforESAandhavethemtransferredtoJSA,orleadtothembeingsanctioned.

4.3SearchingforWork

For those individuals that are assessed as being ready forwork, and placed on JobSeekers Allowance (or the JSA component ofUC), there is an expectation that theydemonstratethattheyareactivelyseekingwork.Thisinvolvesapplyingforjobs,lookingforvacancies,CVwritingandregisteringwithemploymentagencies.Ifindividualsfailtoundertakesuchactivities,thereisapotentialforsanctioning–thatishavingbenefitsstopped.

However,manyofourparticipantsfellbetweenthecracks.TherewerefrequentfailuresintermsofcommunicationbetweenJobcentrePlusandtheDWP-whichonmorethanoneoccasionledtoindividualsbeingsanctioned.Inonecase,anindividualwhohadepilepticseizureswhenhelookedatacomputerscreenwassanctioned,forfailingtolookforvacanciesataJobcentre,astheonlymechanismforsearchingforworkwasonacomputer.

For those that had been out of work for a long period of time, or were close toretirement age, therewas a concern that theywould never be able to re-enter thelabourmarket.Participantsfeltthattheywereseenastoooldorthattheirqualificationswereseenasdated.

“Imeannoone,noonewouldemploymeatall.Eventhough,youknow,Idon’tblowmyhornbutIdoperformbetterthanmostoftheothersupportworkers.I’maveryprofessionalpersonwhen I’m inworkyouknow?But Iwasn’tgiven thechancebecauseIdidn’thavetheemploymenthistory.Thatwasthemainthing”(Ken)

Therewere frequent tensionsbetweentheperceptionsofmedicalprofessionalsandrepresentativesoftheDWP.Participantsthathad‘failed’theirWCAandbeenplacedonJSAwereoftendeclaredunfitforworkbytheirGP.So,participantshadtocomplywithDWPrequirementsandbeingseentobeengagingwithasearchforwork,inordertoavoidbeingsanctioned,yetweredeclarednotfitforworkbytheirownGP.

4.4Summary

TheputativeaimsoftheWCAaretofacilitatethe(re)entryoflargernumbersofintothelabourmarket.However,thecurrentsystemisflawed.Itfailstoallowthosepeoplethatwanttoengageinvoluntaryworkorwork-relatedactivitytoenactthisastherearepotential‘penalties’intheformofareductioninpointsintheWCA.Asaconsequence,whenpeopleareinapositiontore-enterthelabourmarkettherearefrequently‘gaps’

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in their CVs.Moreover, as the next sectionwill describe the process of theWCA isfrequently sodisruptive that any attempt at voluntaryworkorwork-related activityceasesleadingtofurtherproblemsintermsofdevelopingemployabilityskills.

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5. TheImpactoftheWCAandBenefitsSystemonIndividual’sMentalHealth

5.1Introduction

Theaimofthissectionistoexploretheimpactofthebenefitssystemonthementalhealthoftheparticipants.WefocusonthenegativeexperienceoftheWCAandthedamagingeffectoftheassessmentonparticipants.Theinflexibilityofthesystemwaswidelynotedbyparticipants,withphasedreturnsandtheadviceofhealthcareworkersoftenbeingsupersededbytheprioritiesoftheWPtogetpeoplebackintowork.Thissection will also look at the multiple forms of stigma that are faced by benefitsclaimants.

5.2TheDamagetheWCACanCauseVirtually all participants that had been through the WCA found the experienceemotionallydamaging.TheWCAfrequentlyfailedtoadheretoappointmentschedules.Having to sit in a room, for up to anhour,waiting for an assessment presented anextremelystressfulsituationforpeoplewithamentalhealthcondition.Moreover,thefeelingofbeing judged,havingto justifyingtheirconditiontoastranger,andfeelingthatthereisapossibilityofbeingmadetoreturntowork-whilststillfeelingveryunwell-wasverydestructiveforparticipants.

‘IthinkthelaststatswedidwereinAugustandsomethinglike60%ofthemsawadeteriorationintheirmentalhealth,with15%ofthemfeelingsuicidalwithit….Theyjustgotsoanxiousaboutit.Ithinkalotofitistodowithwhattheyseeinthemedia.Itdoesn’thelpandIkeepsayingtopeople,“Whenyougettheletter,don’tGoogleit.Whateveryoudo,don’tGooglewhattodoinyourassessment,becauseyou’lljustgethorrorstories,”buttheydoanditjustmakesthemworse,becausetheyreadalltheseotherstoriesandthink,“Thisisgoingtohappentomeandthey’regoingtomakemedothis,”andIkeepsaying...theymakethemselvesworseandthensometimesit’squitealengthyprocess.Fromfillingintheformtogettingyourletterthroughforyourassessmenttogettingyourassessmentandthengettingyouraward,itcantakeaboutsixmonths,andallthetimethey’vegotthatovertheirhead,“Imightbelosingmybenefit,theymightmakemegobacktoworkandI’mnotreadytogobacktowork.”Graduallytheystarttogetworse”(Andrew,AdvocacyWorker)

5.2ExperiencesofStigma

A theme that emerged throughout the research was the experience of stigma forparticipants.Whilediscussionsofmentalhealthandstigmawerecommon,formostoftheparticipants,thestigmaofclaimingbenefitsorbeingseentobeunemployedwasafarmore illustrativeof thesocialproblemsmanyof themexperienced.Forexample,Jessicadescribestheoccasionsthatshehadtoaccessacrisisgrant.

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“andhe said tome that theremustbeablackhole somewherewithall theselettersinitbecausewekeephearingthisandpeoplearehavingtophoneforthisandIthought“ThankGod,he’sactuallylistening,hesoundslovely,hesounds…he’sgotempathy”andhesaystome,“sofinancially,tellmewhatyou’vehad”andIsaid“Ijustgotpaidtodaybut£38ofthatcameoutinbankcharges”andinstantly,histoneofvoicechanged.Andhesays,“well,doyouknowwhat,yougotyourselfintodebt,soyouhadtopaythesecharges,soI’mnotwillingtohelpyou.”Thatwashisexactwords.Iactually,Iwasinshock,IjustfrozeandIdroppedthephone–andIwentintoapanicattack.Icouldn’t…Ihadlessthan£20toliveonandthenextlotofmoneythatwascominginwouldhavebeen5dayslater,whenIgotthe£20childbenefit.SoIhadlessthan£20tolivefor5days,withachildandIwashavingtoputthatintothegasandelectricity–soIhadnomoneyfor 5 days. I had nomoney and thisman toldme he’s notwilling to helpmebecauseyougotyourselfintodebt”(Jessica)

Reflectiveofanumberofacademicstudies(e.g.Baumbergetal.,2012),participantscitedmediaportrayalsoftheunemployedasacauseofstress.Theseparticipantsarguedthatthemediadiscourseleftthemfeelingstigmatisedbecausetheywereoutofwork.Withintheseaccounts,manyfeltthattheyweredisadvantagedbythelackofaphysicalrepresentationoftheircondition.

“I do find the stigmatisation has occurred because there’s been such mediabacklashagainstpeople.Becausetheyseesomeoneinawheelchair,whocan’twalkorwithadisabilitytheycanseephysically[]andbecausepeoplelikemyself,whodon’texhibitonadisabilityphysicallyasahandicap.Wehaveahandicapinourmindandbecausewecan’t,wecan’t…it’snotasclearlyseenbecauseit’sinthe subconscious in yourmind. And because they can’t see that, you are thendemonized-soallthebacklashislikewe’reskivingoffwork,wedon’twantworkand I thinkthewholemedias’overdramatisingand it’sbeen likeawitchhunt”(John)

Indeed,reflectiveofthecommentaryinSectionThreeinrelationtothelackofphysicalevidenceofamentalhealthcondition,Philexplainedhowitisnecessarytodemonstrateillhealththroughothermeans.

“WhenIpassedtheappeal…andwhenIpassedIwassmilingandIwaswalkingdownthehallgoing“thankGodthat’sover”andIwascheery.AndthepeoplethatIwaswiththeywereanadvocacyagencysaid…“Stopsmiling”andIthoughtthatwasreally…Ifelt,actually,quiteupsetaboutthefactthatIwasn’tallowtoenjoythefactIhadpassedmyappealbecausetheyareobviouslythinking“itlookslikeyou’regamingthesystem”orsomething,youknow.Andthatmademefeelreallybadthat Icouldn’tactuallybegenuinelyhappybythefactthat I’dbeenfoundsick”(Phil)

Aroundone-thirdoftheparticipantsreportedexperiencingphysicalillnessesinadditiontotheirmentalhealthcondition.Iain’saccountdemonstrateshowaphysicalconditionistreatedinaverydifferentmannertoaMHC.WhileclaimingESAforhismentalhealthcondition,Iaindevelopedcancer.Herecountedhow“relieved”hefelttohavephysicalevidenceofillness:

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It’sfrustratingbecausepeoplegenerallythinkI’mlookinghealthierthanIwas…andtheythinkI’mokaybuttheydon’tknowwhat…ontheoutside,whenIgetbacktomyhouse,Igointoadifferentworld:it’sjustshambolic.ButwhenIhadmyearcancertreatmentIhadabandageonmyheadanditwasgreatbecausepeoplecouldseetherewassomethingwrongwithme[laughs]…andIsaystothenurseatthehospital“Ishouldcomehereandgetafalseplasteronmyarmorsomething…sopeoplethinkI’millallthetime,becausepeopledon’tseeanythingwithme”(Iain)

5.3Summary

The findings of this section indicate that the process of claiming benefits andundertaking the Work Capability Assessment lead to greater stress and worseningmentalhealth.Theclaimantsinterviewedforthisresearchandtheadvocacyworkerswe spoke to all noted that theprocesses put in placeby theDWParedamaging towellbeing.TheuncertaintyofbeingonESAandthestressofpotentialreassessmentsfrequentlyledtoasituationwhererecoverywasimpossible.TherewasaperceptionbyparticipantsthatmanagingtheirMHCsisseenbytheDWP,assecondarytoreturningtoemployment.Thereisaperceptionbyparticipantsthatbeingoutofworkandlackingphysicalsignsofillnessisviewedsociallyasbeinga‘shirker’.

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6. ConclusionsandRecommendations

MentalhealthproblemscosttheeconomyofGreatBritaininexcessof£40billioneachyear2(excludingthevalueoftheireffectonthequalityoflifeoftheindividual).Abouttwothirdsofthecostisduetotheirimpactonpeople’sabilitytowork.About11millionpeopleofworkingageinGreatBritainexperiencementalhealthproblemsandabout5.5millionhaveacommonmentalhealthcondition.There is some evidence that the adverse impact ofmental health problems on theeconomy is growing faster than that of physical health problems with a significantproportionofpeoplewhoareclaimingtheESAcomponentofUChavingaMHC(over40%).Althoughtheyonlyaccountsfor15%ofallclaimsforDLA,mentalhealthproblemsarenowthecommonestcauseofnewclaimsOurresearchhasreinforcedthefactthatpeoplewithmentalhealthproblemsfacemorestigma and discrimination than those with physical health conditions and that thisdiscriminationisbuiltintotheWCA.ThepoorconsiderationofmentalhealthisoneofthefactorsthatseemstoleadtotheWCAexacerbatingexistingMHCsaspeoplewithMHCs are frequently assessed inaccurately and have to fight for reconsideration orstruggletoreturntowork.Thereisaseparationbetweenprimarycareworkers,theWCAassessors,theDWPandJobcentre Plus. This results in a failure to present a coordinated approach to theconsideration of health and whether, or how, return to work is possible. Despitechanges in recent years, there is still a “benefits trap” for somepeoplewithmentalhealthproblems.Contradictingmediaaccountsofpeopleonbenefitsbeing‘workshy’,wefoundthatmostofourparticipantswantedtobeengagedinsometypeofwork-basedactivity.The opportunity to engage in work-related activity is however, made near onimpossible.Manyofourparticipantswereundertakingworkexperienceorvoluntarywork,yetatthepointofundertakingtheirfirstWCAtheassessmentexperiencewassodamagingtheystoppedengaginginanywork-basedactivityanddidnotreturntoit.Thisfurther reduces long-term employability and potentially increases dependency ofbenefits. Moreover, there was a perception from assessors that if someone canundertakevoluntaryworktheycanmanagepaidwork.Thisisanaïveperspective.FormanypeoplewithsevereandenduringMHCs,voluntaryworkmaybe‘asgoodasitgets’andthere isa failure inthesystemtosupportandrewardthis. It ishopedthatwithsomeprovisiontodevolvewelfare-to-worktotheScottishGovernment-ascontainedintheScotlandAct2016–thevalueofvoluntaryworktobothsocietyandtheindividualissomethingthatcanbeaddressed.2WedohavespecificfiguresforScotlandavailable.

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PreliminaryRecommendations

• TheWCAneedstobeentirelyre-writtenandre-defined.Questionsneedtofocuson the potential barriers towork for a variety of physical andmental healthconditions

• Assessmentsalsoneedtofocusonwhatpeoplewanttodoandwhatcanbeputinplacetoaidtheirplan

• There needs to be closer and more effective contact between the DWP,JobcentrePlusandtheWCAproviders.

• The WCA is likely to be more effective if it is not outsourced to privatecontractors

• TheWCAneedstoruntotimeandbeconductedbyindividualsthataretrainedinthespecificsofanindividual’scondition

• More weight needs to be given to recommendations and reports from GPs,Psychiatristsandothermedicalprofessionalsworkingwithclaimants.

• Greater value needs to be placed on voluntary work and work-preparationactivity

• Theassumptionthatengagementinvoluntaryworkmeansthatanindividualisfitforemploymentshouldbeeliminated

• There needs to be greater flexibility in terms of opportunities to undertaketrainingwhilstonESA

• Thereneedstobeacknowledgementthatengagementinvoluntaryworkmaybeas‘goodasitgets’forsomepeoplewithaMHC

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ReferencesBaumbergB.,Bell,K.,Gaffney,D.,Deacon,R.,Hood,C.andSage,D.(2012)BenefitsstigmainBritain.UniversityofKent.ButterworthP,RodgersB,andWindsor,TD(2009)Financialhardship,socio-economicpositionanddepression:resultsfromthePATHThroughLifeSurvey.SocialScienceandMedicine69:229-237Davies,B(2014)Insafehands?EvaluatingemploymentpathwaysforESAclaimantswithmentalhealthproblems.http://www.ippr.org/publications/in-safe-hands-evaluating-employment-pathways-for-esa-claimants-with-mental-health-problemsDWP(2015)2010-2015GovernmentPolicy:Employment.https://www.gov.uk/government/publications/2010-to-2015-government-policy-employment/2010-to-2015-government-policy-employmentHMT(2014)AutumnStatement2014.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/382327/44695_Accessible.pdfKing,N(2004)Usingtemplatesinthethematicanalysisoftext,inC.CassellandG.Symon(Eds.)EssentialGuidetoQualitativeMethodsinOrganizationalResearch.London:Sage.LitchfieldP(2013)Anindependentreviewoftheworkcapabilityassessment-yearfour.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/265351/work-capability-assessment-year-4-paul-litchfield.pdfMarksA,RichardsJandLorettoW(2012)Whatworks?:Supportingmentalhealthintheworkplace(ExecutiveSummary).Glasgow:SAMH.TheSmithCommission(2014)TheSmithCommissionReport.https://www.smith-commission.scot/smith-commission-report/SAMH(2014)WorriedSick:ExperiencesofMentalHeathandPovertyAcrossScotland.http://www.samh.org.uk/media/432022/samh_worried_sick_poverty_and_mental_health.pdfStickleyTandWrightN(2011)TheBritishresearchevidenceforrecovery,paperspublishedbetween2006and2009(inclusive).Partone:Areviewofthepeerreviewedliteratureusingasystematicapproach.JournalofPsychiatricandMentalHealthNursing,18,247-256.WaddellG.andBurtonAK(2006)Isworkgoodforyourhealthandwellbeing?London:DepartmentforWorkandPensionsWarnerR(2004).RecoveryfromSchizophrenia:PsychiatryandPoliticalEconomy(3rdedition).Hove:Brunner-Routledge.

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ProfessorAbigailMarks a.marks@hw.ac.uk

DrSueCowan s.cowan@hw.ac.uk

DrGavinMaclean g.maclean@napier.ac.uk