Unemployment and mental health asu

Unemployment and psychotherapy Mental illnesses are closely linked to unemployment. They can be a cause and a consequence. Especially when unemployment lasts for a long time, the risk of mental illness increases. There are successful prevention, health care and workplace reintegration measures for people with mental illnesses. However, these need to be more mainstreamed in the future. Psychotherapists have an important role to play here. Dietrich Munz, Theresa Unger, Johannes Klein-Hebling

Unemployment – a threat to mental health

Unemployed people have poorer mental health than employed people. This is proven by a large number of studies (for an overview z. B. Paul u. Moser 2009; Mohr u. Hollederer 2015). They are more likely to suffer from stress-related symptoms, depression, anxiety and psychosomatic complaints. Among them, the proportion of those with clinically relevant mental health problems is twice as high as among employed persons (16 vs. 34 %; Paul u. Moser 2009).

The data of the health insurance companies show a comparable effect. According to the current BKK health report, mental illnesses were diagnosed significantly more frequently among recipients of unemployment benefit II, at 41 percent, than among employed compulsory members, at 29 percent (Knieps u. Pfaff 2016). Analyses of work disability data also point in the same direction. Unemployed people are more often on sick leave because of mental illness than employed people. For example, data from the BKK show that mental illnesses are responsible for 14 percent of days of incapacity to work among employed compulsory members, but for 36 percent among recipients of unemployment benefit I (Knieps u. Pfaff 2016).

Overall, these figures show that mentally ill people are significantly overrepresented in the group of unemployed and job-seeking people – this is especially true for unemployment benefit II recipients. The presence of mental illness is a barrier to placement among the unemployed (Paul u. Moser 2009). In order to increase their chances of re-entering the workforce, special attention should be paid to this group of people. Psychotherapists can help here. Psychotherapists play an important role.

Unemployment and mental illness – the chicken-and-egg problem

However, before we turn to the question of how psychotherapists can help stabilize and restore the mental health of the (long-term) unemployed and increase their chances of re-entering the workforce, we will answer the question of why mental illness is disproportionately prevalent among the unemployed. Do mental illnesses lead to unemployment or does unemployment itself cause the mental illness??

The hypothesis that workers with mental illnesses are more likely to become unemployed and less likely to find a new job is known as the selection hypothesis. Accordingly, psychological impairments are a factor in company dismissal and hiring practices that should not be underestimated (Schubert et al. 2013). The amption that unemployment itself causes mental illness is known as the causality hypothesis. Most studies show that both the selection and causality hypotheses apply, with the effect of unemployment being more relevant for the causation of mental illness (Paul u. Moser 2009).

Overall, it can be stated that unemployment and mental impairments reinforce each other in the sense of a negative spiral ( Fig. 1). Mental illness may increase risk of job loss. Unemployment can then exacerbate mental health problems or unemployment can cause mental health problems. These can then worsen the chances of re-entering the workforce, which in turn can perpetuate or even exacerbate the psychological complaints. Thus, those affected find themselves in a vicious circle of (long-term) unemployment and mental illness, from which they cannot find their way out without support.

Psychological functions of work

But why does unemployment make people mentally ill? Unemployment is a heavy burden for many of those affected, which goes far beyond financial restrictions. There are several explanations for why unemployment causes mental health problems (for an overview z. B. Mohr u. Hollederer 2015). The best known theory is Jahoda's (1981) latent deprivation model. According to this hypothesis, work has five significant psychological functions: Work structures time, mediates status and provides meaning. It also enables social contacts. The involvement in social goals. The loss of these latent functions of work due to unemployment has negative effects on mental health.

Psychologically healthy despite unemployment – what can psychotherapists do??

For people with mental impairments, finding, taking, and keeping a job is associated with a variety of challenges and problems. These include illness-related motivation problems, lack of drive and social contact problems (Schubert et al. 2013). It is therefore important to take preventive action at an early stage to prevent unemployed people from becoming mentally ill. If they are already ill, they should be helped promptly to overcome the mental illness. Only a person who has sufficient psychological resources, social skills and self-confidence can appear confident in a job interview, cope with rejections and master the challenges of a career re-entry (Mohr u. Hollederer 2015).

Psychotherapists play an important role here. They are experts in recognizing. Treatment of mental illnesses. Their expertise is also needed in the prevention of mental illness and in the reintegration of mentally ill people into the world of work. This results in three areas of action for psychotherapists when it comes to the mental health of the unemployed:

– Primary prevention of mental illness among the unemployed, – Early detection and treatment of unemployed people who are already mentally ill, – Support for mentally ill people returning to work.

In this context, it is essential that health-related and work-promotion measures are closely interlinked and that there is close cooperation between psychotherapists, employment agencies, integration specialists and occupational physicians.

Prevention of mental illness among the unemployed

The most important preventive measure for preventing mental illness among the unemployed is successful placement in new employment. The earlier re-employment follows, the lower the psychosocial burdens associated with unemployment tend to be. Conversely, the risks to mental health increase especially in the first nine months of unemployment (Otto u. Scheel 2014).

At the same time, the chances of re-employment decrease due to a mental illness. Measures to promote mental health are therefore the second pillar of prevention alongside job placement. The aim is to strengthen psychological and social resources to cope with the psychological stresses associated with unemployment.

Framework of the Prevention Act

The Prevention Act has created new framework conditions for prevention and health promotion and for the necessary cooperation between the social insurance funds. In the federal framework recommendations of the National Prevention Conference according to § 20d para. 3 SGB V, the fields of action for the target group of the unemployed are described with regard to the goal of "healthy work". Unemployed people, as a socially disadvantaged group, have a special need for health promotion and prevention. In order to meet this need for support, the statutory health insurance funds are to cooperate with the employment agencies and job centers. While the measures of the statutory health insurance funds pursue the goal of preventing health restrictions of the unemployed so that they maintain or improve their health and earning capacity, employment agencies and job centers should integrate health orientation as an overarching action strategy in their counseling activities. Via job centers and employment agencies, low-threshold access is to be created to the behavioral and relationship-preventive prevention offers of the health insurance funds, which are to be made available to participants free of charge as a setting measure across all insurance funds.

Model project for cooperation between job centers and health insurance funds

The cooperation between job centers and health insurance funds was investigated in a model project (Schreiner-Kurten et al. 2016, s. "More Info"). Course programs developed and evaluated by the health insurance funds for the target group of unemployed people focus on stress management. In the "JobFit" program, the field of action stress management was supplemented by elements on exercise and nutrition. The "AktivA" program includes the elements of activity planning, constructive thinking, social skills and systematic problem solving. In addition, u.a. offer topic-related information events, workshops, health circles or health days. The evaluation results show that the linking of health orientation, especially with the focus on mental health and integration work, is welcomed by the participants. Positive effects on health behavior were also evident. The health-related quality of life. The positive effects can probably also be attributed to the fact that the model project met quality standards formulated by Mohr and Hollederer (2015) for measures of labor market-integrative health promotion among the unemployed.

Successful prevention programs to prevent mental illness among the unemployed should include u.a. include the following (Otto u. Scheel 2014):

– Elements to promote self-efficacy and self-confidence, – Elements to promote a sense of coherence, and – Measures to promote "life skills".

Psychotherapists are experts in promoting specific health-related competencies and are therefore qualified to implement z.B. of relaxation, communication, self-management, conflict or stress management training as part of behavioral preventive measures. Targeted psychotherapeutic interventions may also be necessary in some cases.

Early identification and treatment of unemployed people with mental illnesses

Interventions such as JobFit or AktivA are helpful in strengthening the psychological resilience of the unemployed and reducing the risk of developing mental illnesses. However, they are not a substitute for psychotherapy (Mohr u. Hollederer 2015). When an unemployed person is mentally ill, preventive measures are no longer enough. Then it must be a matter of identifying the mental illness at an early stage, selecting the right treatment and then initiating it promptly. This requires rapid access to psychotherapists. Because the number of psychotherapists in private practice is too low in many places, patients have had to wait an average of three months for a first consultation with a psychotherapist, and an average of half a year for the start of psychotherapy (BPtK 2011; s. "Further Info").

Psychotherapeutic consultation hours and acute treatment allow for quick help

This will change in the future. Since April 2017, people with mental health problems have been able to seek counseling from a psychotherapist at short notice. Psychotherapists offer consultation hours for this purpose. People seeking advice can thus get an initial appointment much faster than before.

In addition to consultation hours, there have been other changes in outpatient psychotherapeutic care since April 2017 that make it easier and faster to reach psychotherapists. For example, in the future, psychotherapists must be available by telephone for 200 minutes per week. In addition, there is the possibility of acute treatment after the consultation hour. This acute treatment is intended for mentally ill people who would become unable to work or would have to be admitted to hospital without it (for more information on the innovations in outpatient psychotherapeutic care: BPtK-Praxis-Info on the Psychotherapy Guideline, s. "Further Info").

These changes can help to facilitate access to the established psychotherapist for the unemployed and to offer them at least faster first help. Overall, however, the innovations do not increase the number of psychotherapy places, but rather make the scarce resource of psychotherapy even scarcer. The Federal Chamber of Psychotherapists therefore continues to vehemently advocate for a reform of demand planning that leads to a more demand-oriented number of psychotherapists in private practice and reduces not only waiting times for an initial consultation but also for psychotherapeutic treatment.

Training for employment agencies

The psychotherapeutic consultation allows those seeking advice to receive detailed diagnostics and advice at an early stage. Many people, however, hide the fact that they have psychological problems for fear of stigmatization and do not seek professional help. This is also – and probably especially – true for a large number of unemployed people. Many of them therefore need the support of employment agencies in order to find their way to a psychotherapist. Employment mediators and integration specialists are thus often in the very first place on the path to treatment.

However, identifying a special need for support due to mental impairments is a major challenge (Schubert et al. 2013). Often, employment agencies do not have the specific expertise in types of illness and consequences of illness, so they often fail to recognize psychological impairments (Schubert et al. 2013; Mohr et al. Hollederer 2015). Better qualification of employment agencies to recognize psychotherapeutic counseling needs can sustainably improve the interface between employment agencies and the health care system.

Psychotherapists can help here. Training sessions were designed to inform employment mediators and integration specialists about typical complaints of mental illness and access routes to the care system. You should learn how to recognize the need for psychotherapeutic counseling and how to address the health restrictions of mentally ill clients in counseling sessions. In addition, psychotherapists can teach employment agencies to adjust their interviewing behavior to people with mental health problems. For example, in the case of depressively ill people, a supportive and accepting approach will be better than an emphasis on the obligations to cooperate, which depressively ill people are often unable to meet to a sufficient extent due to depressive symptoms such as listlessness and concentration disorders (Schubert et al. 2013).

Regional networking and cooperation

In order to be able to identify and treat mentally ill unemployed people at an early stage, there must be comprehensive and effective regional cooperation between employment service providers on the one hand and health care providers on the other. One example of such cooperation is the model project "AmigA – Arbeitsforderung mit gesundheitsbezogenen Ausrichtung" (MASF Brandenburg 2008, s. "More Info"). The aim of the project was to increase the number of unemployed people with placement-relevant health impairments who were sustainably integrated into the labor market by including health aspects and health-related services in employment-oriented case management. For this purpose, the unemployed were cared for by a team of placement specialists, a social physician, and a psychological psychotherapist. The task of the doctor and psychotherapist was to participate in case management and the integration process and to act as a pilot in the health sector.

Such interdisciplinary support for unemployed people with health problems should be made possible nationwide as part of employment-oriented case management. There is a need for stronger networking between employment services and health care that goes beyond individual projects and is firmly anchored in the system. Due to the limited number of appropriately qualified specialists in the medical service of the Federal Employment Agency (Schubert et al. 2013), it may also be useful to further develop structures for involving external psychotherapeutic or psychiatric evaluators, especially those who are already treating the affected person.

Support for the professional re-entry of mentally ill persons

However, mentally ill people do not only need support during the time of job search. Particularly in the case of chronically mentally ill people, support is often necessary after they have taken up work. Vocational re-entry is strenuous. It is fraught with many challenges. Great adjustment efforts associated. Potential employers also see this and demand that in the event of psychosocial crises or even conflicts at the workplace, immediate and reliable professional help is provided for those affected and for the company (Schubert et al. 2013).

This is where psychotherapists can help. Together with those affected, company physicians and companies, they can develop suitable measures to make it easier for mentally ill people to return to work and provide advice on any problems that may arise. Cooperation between the treating psychotherapist, the company doctor and the company can help, on the one hand, to take into account the company framework conditions and requirements for psychotherapeutic treatment and, on the other hand, to design the working environment in such a way that the return to work is possible.

What remains to be done? – An outlook

The conditions for promoting the mental health of the unemployed have improved. There is extensive basic knowledge about the links between (long-term) unemployment and mental health, and a good body of research on how to influence it. At the same time, there is a large implementation deficit, which is why mental illnesses continue to pose a high individual risk for prolonged or unnecessarily long periods of unemployment.

Changes in the framework conditions for the prevention of mental illness and the care of mentally ill people offer good opportunities to eliminate or at least reduce this implementation deficit. What contribution the Prevention Act will make to this remains to be seen. Here it will be important that the changes in the framework conditions and their effects are well documented. With regard to prevention, a correspondingly differentiated presentation according to target groups is to be demanded in the prevention report. Then it will become clear whether it has been possible to bring successful models into the area.

The same applies to the introduction of psychotherapeutic consultation hours and acute care. They can be effective elements for the early detection and treatment of mental illnesses, also among the unemployed, and thus shorten the duration of unemployment. The extent to which these instruments actually achieve the goals attached to them remains to be seen. The Federal Chamber of Psychotherapists will conduct its own evaluation study on this topic.

There is room for improvement in the cooperation between psychotherapists and employment agencies in order to get those who need treatment into treatment quickly. This can be helped by appropriate training of those involved on both sides. On the employment services side, it is about knowledge about mental illness and referral to care services. There is still room for improvement among psychotherapists in taking into account the work-related aspects of psychotherapy. There is also comparable potential with regard to cooperation with company doctors.

In addition to these partial aspects, however, it is also fundamentally a question of the status of mental illness in our society. There is still too much ignorance and too many prejudices regarding mental illness and mentally ill people. Only on the basis of better education of the population about mental illness will mentally ill people have better access to the labor market and be employed according to their possibilities and special needs. Greater involvement of psychotherapists in the prevention and professional reintegration of mentally ill people can be an important part of this.


Jahoda M: Work, employment, and unemployment: values, theories, and approaches in social research. Am Psychol 1981; 36: 184-191.

Knieps F, Pfaff K: BKK Health Report – Health and Work. Berlin: Medizinisch Wissenschaftliche Verlagsgesellschaft, 2016.

Mohr G, Hollederer A: Labor market integrative health promotion for the unemployed. In: Badura B. et al. (ed.): Absenteeism Report 2015. Berlin: Springer, 2015, pp. 235-247.

Otto K, Scheel T: Mental health and unemployment: interrelations and interventions. In; Klein-Hebling J, Krause D (eds.): Mental health in the world of work. Heidelberg: Medhochzwei, 2014, pp. 65-76.

Paul K, Moser K: Unemployment impairs mental health: Meta-analyses. J Vocat Behav 2009; 74: 264-282.

Schubert M et al.: IAB Research Report – People with mental disorders in SGB II. Nuremberg: IAB Research Report, 12/2013.


"Psychotherapists" may call themselves three professional groups: Psychological psychotherapists, child and adolescent psychotherapists, and physicians) (§ 1 para. 1 PsychThG).

Psychological psychotherapists (PP) have first completed a psychology degree and then, after three to five years of training, received their license to practice as a psychological psychotherapist. Child and adolescent psychotherapists (KJP) specialize in the treatment of children and adolescents up to the age of 21. Specialized at the age of. They initially studied pedagogy or social pedagogy resp. Completed a psychology degree and then completed three to five years of training specifically for the age group of children and adolescents with licensure. Medical psychotherapists have completed further training as a specialist in psychiatry and psychotherapy, psychosomatic medicine and psychotherapy or child and adolescent psychiatry and psychotherapy, which qualifies them to conduct psychotherapy, or are specialists in other fields with additional training in psychoanalysis or specialized psychotherapy The state examination for PPs and KJPs covers the areas of prevention, curative treatment and rehabilitation. Accordingly, PPs and KJPs must also demonstrate knowledge of the goals and tasks of prevention, methods, characteristics and objectives of specific prevention programs, as well as environmental and social system-related interventions and methods in the state examination.

Practical example

Vocational re-entry of a patient with an eating disorder

Monika S. (25 years) has been suffering from an eating disorder for ten years. After completing her training as a hairdresser, she had taken on new jobs several times, but never made it through the probationary period because she was frequently on sick leave due to her eating disorder. She has now been unemployed for nine months. In the meantime, her self-esteem is so "in the basement" that she fails in job interviews. Psychotherapy, which the patient started seven months ago, helped her a lot. Her self-confidence has risen. She also has the eating disorder problem well under control, she says. However, the strict observance of meal times is important. A job interview also went well. She has been offered a job starting next month. Now, however, she is afraid of not being able to keep the meal breaks, of falling ill again and of being dismissed again during the probationary period. In order to support the patient's return to work, a joint meeting was arranged between the new boss, the patient and the psychotherapist, in which the boss was informed about the patient's mental illness and the importance of regulated break times with the possibility to eat was discussed. Thus, a return to work was possible, which continues to be accompanied by weekly psychotherapeutic sessions.

Unemployment and mental illness

Overview of services provided by psychotherapists

– Diagnostic clarification in the context of early detection – Interpretation of patterns of findings – Training of employment agencies and integration specialists on mental illnesses, their causes, treatment options and how to deal with and talk to unemployed people with mental illnesses – Supervision of employment agencies and integration specialists – Individual and group training to promote specific skills, Diagnosis and treatment of mentally ill unemployed persons – Consideration of the work context in psychotherapeutic treatment with the aim of increasing placement opportunities – Support for re-entry into the workforce – Cooperation with company physicians


Co-authors of the article are Dr. Theresa Unger and Dr.

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