In 2006, E. Fuller Torrey, an American psychiatrist and schizophrenia researcher, argued that “when the social history of our era is written, the plight of persons with schizophrenia will be recorded as having been a national scandal” (Torrey, 1988, p. 3). Schizophrenia is a serious mental illness (SMI) (or equally, a group of illnesses) characterized by a multitude of symptoms that interfere with a person’s ability to think clearly, manage emotions, make decisions, and relate to others. Despite advances in psychotropic medications, psychosocial therapy, and rehabilitation that have granted many people unprecedented control over their illness, an intense stigma enshrouds nearly everything about the disorder. Individuals with schizophrenia are perceived by outsiders to be unpredictable, incoherent, and floridly psychotic with no hope for recovery. It is perhaps unsurprising, then, that these individuals should experience profound difficulty in finding acceptance and gainful employment.

It turns out that many individuals with schizophrenia are willing and able to work, a fact scarcely reflected in this group’s inordinately high unemployment rates. As a health economist specializing in disability-related discrimination, author Marjorie Baldwin believes stable and gainful employment is intricately tied to a person’s sense of dignity and worth in our society. “In a very real sense,” states Baldwin, “work is a source of identity” (p. 93). For people with SMI, regular work that pays a living wage provides a daily routine and structure, a sense of purpose, enhanced self-confidence, and opportunities for social inclusion. Work is also a social determinant of mental health and when made available, recovery outcomes for individuals with SMI tend to improve. After her son was diagnosed with schizophrenia during his junior year of college, Baldwin’s research interests shifted to the study of workers with SMI in the labor market. Her experience of being ensnared inextricably in the chronology of her son’s illness allowed her to witness the potent effect work had on her son’s recovery. Beyond Schizophrenia is powerful and moving dual account of Baldwin’s research as an economist and disability studies scholar and her experience as the mother of a son with schizophrenia. It provides fresh insights into the relationship between employment outcomes and SMI, a topic too often neglected in mental health policy.

Structurally, the main body of text is bifurcated into two sections, with Baldwin’s experiential second-hand narrative of her son’s schizophrenia adeptly woven into each of the twelve chapters that comprise the book. The first section examines the effect various societal factors have on the lived experience of schizophrenia, including stigma, discrimination, quality and availability of mental health services, and caregiver burdens. The second section identifies workplace factors that impact employment outcomes for individuals with schizophrenia, including employer mandates in federal antidiscrimination legislation, job matching, the decision to disclose a mental health diagnosis to an employer, and job accommodations. The final chapter addresses Baldwin’s agenda for change. Here she issues a call for more enlightened mental health policies by proposing a set of bold policy recommendations aimed at improving employment outcomes for individuals with schizophrenia. These recommendations are united in their underlying commitment to the belief that the best way for individuals with SMI to acquire what economists refer to as human capital—the intangible productive potential that employers find valuable—is through education, skills training, and access to healthcare. A recurrent theme of this book is that improving employment rates for people with SMI requires a shift in focus from demand-side economics concerned with maximizing profits and minimizing risks in business to supply-side economics concerned with finding jobs for individuals with SMI that are consonant with their needs. To date, federal antidiscrimination legislation such as the Americans with Disabilities Act (ADA) and its amendments, have failed to increase the employment rates of individuals with schizophrenia. The ADA represents a demand-side disability employment policy that focuses almost exclusively on employer-provided accommodations. “Although well-intentioned,” Baldwin argues, “disability employment policies that focus on employer-provided job accommodations are inherently condescending, such policies emphasize the limitations associated with disability, and implicitly assume that workers with disabilities must be treated differently from others” (p. 138). According to Baldwin, to boost economic growth rates for individuals with SMI, disability employment policies must ensure that individuals with SMI acquire human capital that is valued by employers. This can be accomplished with interventions that “focus on the supply side of the labor market” and “are inherently empowering because they emphasize the capabilities and autonomy of the worker with SMI” (p. 139). Job matching is an example of a supply-side intervention that is tasked with identifying a job opportunity where “the worker’s functional limitations have little or no impact on important job functions” (p. 129). While proper job matching is highly individual, a good match for a typical worker with schizophrenia includes a flexible, supportive, and respectful workplace culture that enables him or her to make use of their skills and talents and achieve their full potential. Baldwin’s claims are bolstered by a first-of-its-kind study in which she provides quantitative evidence supporting the hypothesis that job matching leads to successful employment outcomes for people with schizophrenia.

A shortcoming of this book is the lack of attention paid to attitudinal prejudice and systematic discrimination against individuals with SMI within the context of capitalism. Although Baldwin reserves a chapter for the topic of stigma in the first section of her book, the specific policy recommendations that come later fail to fully address the complexity of stigma and the ways in which negative stereotypes, prejudice, and discrimination are beyond the reach of antidiscrimination legislation. Before an employer provides an accommodation, indeed before the ADA requires that one be provided, an employee must disclose his or her diagnosis. However, many individuals with SMI—especially schizophrenia—do not disclose their illness to their employers or request accommodations for fear of how others will react towards them. By disclosing a diagnosis of schizophrenia, an individual risks discrimination, harassment, isolation, and stigmatizing assumptions about his or her ability. In addition, stigma is so pervasive that people who disclose their SMI to an employer may be denied promotions or other opportunities for advancement. Even in supportive workplace environments, employees with schizophrenia may feel increased scrutiny from their peers. These stigmatizing views held by employers and colleagues make it difficult, sometimes impossible, for people with schizophrenia to enter the job market.

One troubling aspect of the book was Baldwin’s depiction of her son’s religiously-oriented recovery from schizophrenia. She proselytizes when she describes her son’s decision to stop taking anti-psychotic medication as part of a divine plan: “When God was ready, it was time to let go of the medications; David let go and let God” (p. 143). Given the similarities between some reported religious experiences and psychotic, hallucinatory episodes, it seems somewhat irresponsible to suggest religion as treatment (and the forgoing of medical treatment) without also noting the hindrance religion can have on recovery (Weber & Pargament, 2014). This is not to say that the personal details of what has allowed her son to remain “virtually symptom-free” (p. 7) for years should detract from the overall message of this book. This narrative detail represents anecdotal data pertaining to one person’s recovery. It would be wrong to dismiss the importance of religion as anecdotal data to a particular person’s recovery. It would also be wrong to permit unbridled enthusiasm for this potentially positive role of religion to obscure its difficulties. In the face of pernicious social stigma, religious communities might offer refuge amid an indifferent and rejecting society. This appears to resemble the situation of Baldwin’s son. After all, it was her son’s relationship to the church that exposed him to the benefits of meaningful employment. As personally objectionable as I found this small portion of the text, I do not believe it compromises Baldwin’s argument or policy recommendations for improving employment outcomes for people with schizophrenia.

Baldwin’s extensive knowledge and lived experience grant her an insight into the topic of schizophrenia and employment outcomes. Although written in an academic style, the text is not obscure. Baldwin demonstrates an assiduous ability to distill complicated economic terminology and research findings from a vast array of studies and to present these in a clear and common-sense manner. Overall, she offers a well-researched and heavily referenced volume that aims to inform current best solutions for increasing competitive job opportunities for people with SMI, including schizophrenia. A must-read for all researchers and policy makers, this book should also be prominently included in the clinician’s library. Her translation of a wide body of economic theory and empirical research data into a set of clear and comprehensible policy recommendations is highly relevant for anyone whose professional interests are aimed at a better integration of theory and practice in mental health research. Additionally, mental health service users and patient advocates and caregivers may find hope and insight from Baldwin’s fascinating and personal look at schizophrenia.

References

Torrey, E. Fuller. Surviving Schizophrenia: A Family Manual. New York: Harper & Row, 1988.

Weber, Samuel R. and Kenneth I. Pargament. “The Role of Religion and Spirituality in Mental Health.” Current Opinion in Psychiatry 27, no. 5 (2014): 358-363.

© 2017 Anna K. Swartz

Anna K. Swartz received her B.A. in anthropology from Wellesley College in 2005. She is currently working on her M.S. in Rhetoric, Theory and Culture at Michigan Technological University where her research interests include bioethics, philosophy of psychiatry, critical theory, and prison reform.