Learning to manage a mental health condition: Caring for the self and ‘normalizing’ identity at work

Abstract

This article examines the internal and external pressures to ‘normalize’ identity in relation to individuals experiencing mental health conditions (MHCs) at work. The data takes the form of three vignettes extracted from a larger empirical study of 60 interviews. These explore the tensions surrounding identity for individuals experiencing MHCs as well as their interventions to suppress exhibiting the condition. The analysis captures a number of competing meanings surrounding identity in relation to learning to care for the self and managing MHCs. Our contribution is to explore the relationships between learning to care for the self and the performativity of ‘normalizing’ identity in managing MHCs at work. It also provides a potential means of integrating Foucault’s ethics of caring for the self with the literature on identity in ways that can be illuminating for those who manage their MHCs and the demands of work through processes of ‘normalization’. This analysis offers theoretical insights regarding how identity work may be self-defeating in exacerbating MHCs and therefore is of some practical benefit for managers, health professionals and those experiencing MHCs since they often leave individuals with little choice but to intensify their attempts to ‘normalize’ their identities.

Introduction

The topic of mental health has been growing in importance in recent years as a wide range of people from schoolchildren to university students, from industrial to office workers and from professionals to high profile celebrities in entertainment, sport and even royalty have declared their experience of mental health conditions (MHCs). ¹ In the UK, MHCs are experienced across the entire age range of the population and are responsible for 20% of long-term workplace absences (CIPD, 2018).

Existing research and policy (e.g. Improving Lives, 2017) has examined some of the challenges and sought to improve the working lives faced by people experiencing MHCs (Stevenson and Farmer, 2017; Work and Health Programme, 2020), and to limit the cyclical trap of their poor working conditions and reduced employment opportunities. For, despite anti-discrimination legislation, the stigma attached to those with MHCs remains (e.g. Woods et al., 2019). Consequently, it is not surprising to find that although 25% of people experience a period of mental ill health in their working lives, few report this to their employer. ² Yet, there is a paucity of studies that examine the experiences of people’s learning about and managing their MHCs in employment that might shed light on different strategies utilized by them and their outcomes (Hennekam et al., 2020).

Identity is a dominant topic across the social sciences (Brown, 2015) because it addresses the crucial interface between society and the individual that is of significance for those with an MHC because of an historical legacy of social stigma and discrimination. Through the presentation and analysis of empirical research, we address some distinctive aspects of caring for the self and managing identity in relation to mental health at work. Our problematic focuses on how individuals experiencing MHCs learn to care for the self and ‘normalize’ ³ their identities as a way of maintaining employment, with sometimes negative consequences.

In analysing our data, we ask two questions: whether reflexively caring for the self to ‘normalize’ identity resolves the problems of managing the demands of employment for those experiencing MHCs; and second, is the ‘normalization’ of identity on the part of MHC employees simply one of deflecting the source of the problem away from the organization and onto the entrepreneurial self, the limitations of which are self-evident in the extracts from the data we present later. These questions were not formulated at the stage of collecting the data, as the researcher allowed participants to describe their lives with as little intervention as possible. They were, therefore, an outcome of an analysis of the data informed by the literature and certain theoretical ideas that enabled us to put together an argument concerning the importance of interrogating identity.

In this analysis we examined the performativity that was a condition and consequence of our participants ensuring coherence between the sense they had of themselves and the image projected that, through others, acted back on the self as the medium and outcome of identity formation. This involves performativity both in the sense of managing the pressures of the intensification of work by ‘living up’ to organizational performance expectations but also in terms of seeking to bring about an identity that is sufficiently ‘normalized’ to avoid attention being drawn to their MHC.

In the light of contemporary concerns about the apparently growing number of people experiencing some kind of a MHC and within the context of an increasing focus on theories of identity within the field of management and organization, this paper offers a number of contributions. First, it provides some original empirical support for advancing knowledge on the ethics of the care for the self (Foucault, 1986) and the ‘normalization’ of identity for those who experience MHCs at work. Care for the self relates to whatever is significant in one’s life (Foucault, 1988), but ‘[t]he full significance of an ethics of care has not yet been thoroughly researched in the field of management and organization studies’ (Randall and Munro, 2010: 3), and more particularly within settings where marginalized identities are in evidence. Also, while ‘normalization’ has been significant in disability studies (Shildrick, 2009), it has not been theorized in terms of identity work as in this study.

Second, it facilitates a development of studies that interrogate rather than take identity for granted, understanding its relation to learning, performativity and applying this empirically to conditions of mental health at work. Through this interrogation, we follow Foucault in his advocacy of resisting the individualizing effects of seeking to sustain, and becoming attached to, particular identities. As we argue, an attachment to identity is often self-defeating largely because identity relies on social confirmations or rejections in continuous social interactions (Mead, 1934) that can never be predicted let alone controlled. For people with health conditions, such an attachment is also self-defeating insofar as it jeopardizes the individual’s own management of their health, by displacing attention on securing a ‘normalized’ identity. For, identity, is necessarily precarious, transitory and forever open to change, challenge and disruption such that any attachment to a solid sense of self is problematic if not a contradiction in terms. Third, and finally, the analysis considers the lessons to be learned and thus what practical implications in managing (comparatively invisible) diversities follow from this research on MHCs at work. It suggests that an understanding of the contradictory and often self-defeating consequences of becoming attached to an identity can help both those with MHCs and employers to acknowledge and perhaps even celebrate difference rather than deny or conceal it behind ‘normalizing’ routines.

The article is organized as follows: It begins with a literature review of identities at work and relates this to discussions of mental health before articulating the analytical framework for the study. The methodological design of the research is then introduced followed by the presentation of the empirical materials that convey the way in which those with MHCs care for themselves as a way of ‘normalizing’ their identities in order to stabilize their employment. In the light of this, a discussion section seeks to develop current theories of identity as they connect to the ethics of care for the self (Foucault, 1986) in relation to our empirical findings. Finally, in the conclusion, we examine the implications of our work for identity and learning in the context of MHCs in the workplace.

Mental health and identity at work: Towards an analytical framework

Identity research in organizational studies has tended to focus on the dynamic relationship between various resources surrounding its accomplishment, construction, regulation or what might be seen as work on the self (Brown, 2015). So, for example, it is argued that identities are regulated by employees linking their sense of self to management demands and thereby becoming ‘more or less identified and committed’ (Alvesson and Willmott, 2002: 620) to the goals of the organization. This and much of the literature within this field is fundamentally focused on ‘identity work’ as individuals pursue particularly desired senses of themselves (Brown, 2015). Not surprisingly, studies on identities have been closely linked with a better understanding of learning processes about the self and their organization (Brown and Coupland, 2015). But perhaps learning is most intense at those moments of tension and indeterminacy where the complacency around settled identities is actually disrupted (Aquino and Douglas, 2003; Petriglieri, 2011) or silenced through certain organizational processes (Foroughi and Al-Amoudi, 2020). Insofar as those with MHCs are often confronted by discrimination and prejudice, they could be seen as extraordinary in their capacity to manage tensions and uncertainty even though their solution of ‘normalizing’ their identity can also have contradictory effects.

Studies on identity work examine how individuals identify with or in opposition to other organizational colleagues (Coupland, 2001) or generate a merging of personal and organizational identities through employers encouraging self-knowledge (Alvesson and Willmott, 2002) or an enterprising self (Grey, 1994). Identity work may also be triggered by stress and uncertainty (Alvesson et al., 2008), crisis (Brown, 2015) or struggle (Beech et al., 2016) – all situations closely associated with how individuals learn about the relationship between themselves and their work organizations.

One consequence of the literature often merely describing or even endorsing, such identity work is that it fails to interrogate our attachment to an identity, thus remaining comparatively uncritical of the conditions and consequences of individuals’ preoccupations with the self (Knights and Clarke, 2017). Broadly, the identity work literature focuses on the, often instrumental, strategies that individuals deploy for securing, maintaining and consolidating an identity through material and symbolic success – one that is ‘higher, better or nobler than the one they currently occupy’ (Thornborrow and Brown, 2009: 356). By default, if not by design, this reinforces neo-liberal, corporate ideologies of competitive individualism that can exacerbate the propensity for people to experience MHCs at work. The identity work literature also fails to question how organizations often shift the responsibility for a ‘life worth living’ on to the individual whose ‘entrepreneurial’ skills are focused on the self (Foucault, 2008: 241) that, in the case of those with an MHC, has suffered abjection (Butler, 1993). However, our research is not all ‘dark’ for our empirical findings suggest that those experiencing MHCs are often pro-active in engaging with practices of reflection and learning. This can provide them with some support in resisting the ways in which their identities are often stigmatized as deficient or deviant. As we shall come to conclude, however, this may turn out to be a poisoned chalice although it is an active rather than passive response to their condition.

Learning to manage marginalized identities in workplace settings has been studied extensively in relation to age (Crozier and Woolnough, 2020; Warhurst and Black, 2017), ethnicity and race (Macalpine and Marsh, 2005), cultural minorities (Slay and Smith, 2011), sexuality (Rumens, 2017), gender (Mathieu, 2009) but limitedly, in relation to disabilities (Jammaers et al., 2016) and MHCs (Elraz, 2018; Hennekam et al., 2020). So far, research on disabilities has drawn attention to matters of diversity disclosure and care (Lindsay et al., 2013), or to team learning (Zhu et al., 2019). In terms of individual learning to self-manage an MHC, some studies have addressed the perspective of the care professional (Bennett and Baikie, 2003; Hanrahan et al., 2011), but very few have explored this empirically or in relation to people with MHC themselves (Randall and Munro, 2010), especially at work through a focus on identity (Brewis, 2004).

This article’s findings are supported by the more critical literature where identities are seen not only in terms of how they are an effect of power, but also a condition and consequence of resistance (Foucault, 2004: 280; Reed and Thomas, 2020). Identities are constituted through regulatory controls or ‘success ethic’ ideologies, but they can be radically transformed where there is resistance to the sense of self within disempowered subject-positions. Critical research often associates identity with performativity (Butler, 1993; Crevani and Hallin, 2017) – a theoretical construct implying processual enactments that have effects both for agency and its audience in projecting and seeking to sustain a coherent sense of self that, of course, almost always fails, thus necessitating continual reiterations (Butler, 1993). ⁴ We employ this aspect to understand performativity as utterances that seek to establish precisely what they claim (Austin, 1962) and in terms of our participants, their own ‘normalized’ identity.

The interrelationship between identity and learning concerns the way that individuals learn to display or, through faking, conceal (Riach and Cutcher, 2014) certain identities through internalizing ‘normalized’ expectations. Indeed, scholars have demonstrated ‘the complexity of identity work and language’ (Tienari, 2019: 576) in attempting to secure a desirable (‘normalized’) persona (Brown, 2015). Crozier and Woolnough (2020) for example, explored the norms of young academics and how they impact upon their fragile identities in developing ‘confidence and credibility’ (p. 149). The argument is that their age rendered these academics marginalized, which they countered by ‘reflexive activity’ leading them to dress and behave as if they were older as a means of ‘building legitimacy’ (p. 165).

These are examples of ‘normalization’, yet they are insightful in their departure from treating the marginalized as mere passive victims of identity designations (Coupland et al., 2008). Of course, individuals are never passive because, as Foucault (1988) argues, the exercise of power is a freedom of some to direct others but that necessarily also involves the freedom of those upon whom power is exercised (Reed and Thomas, 2020). Nevertheless, while it can be intentional, human action is often circumstantial, unplanned, serendipitous or even unconscious and has negative unintended consequences that the identity work literature sometimes neglects.

For example, individuals may declare their MHC in order to secure some flexibility at work but then the unintended outcome can be a stigmatized identity. Indeed, this was a frequent occurrence in our research where the management of MHCs through self-learning and care to stabilize their participation in work (Elraz, 2018) sometimes backfired. Still, caring for the self involves a set of reflexive learning practices (Foucault, 1988) enacted by those with MHCs to generate a life worth living. At the same time, revealing or concealing an MHC can occur by accident or without conscious design as identities are formed, sustained or are negatively impacted by the absence of any positive recognition or feelings of abjection where failing to meet normative demands (Butler, 1993).

Studying MHCs in relation to the ethics of the care for the self can therefore provide an insight on an important yet under-researched area in management and organization. Despite the possible struggle of gaining and maintaining work for these individuals, studies do report that individuals with both severe and mild MHCs hold, and benefit from, jobs in a wide range of sectors (Mechanic et al., 2002). A number of studies have demonstrated how the work itself, the workplace as well as social factors such as a sense of acceptance, belongingness and a balanced routine are significant in the daily lives of people with MHCs (Leufstadius et al., 2009). From an Occupational Health perspective, it is argued that job choices, employment goals (Honey, 2003), working environment, the relationship with employers, colleagues and their understanding of MHCs (Hauck and Chard, 2009) are of the utmost importance for employees with MHCs in the workplace.

Yet, a scan of the literature indicates the paucity of qualitative studies directly addressing how people with MHCs manage their experiences at work and how it is significant for their identities (Corrigan and Matthews, 2003; Elraz, 2018). This is particularly striking given that a key concern of policy and employment reviews is how individuals experiencing MHCs struggle to gain and maintain employment (Stevenson and Farmer, 2017). Furthermore, it is also unclear how those experiencing MHCs learn to understand and care for themselves not just as passive victims, but also as active agents, of their condition and working relations.

Research design

This study is a part of a larger study comprising 60 interviews with people experiencing MHCs (40) as well as employers (10), health professionals and mental health advocators (10) through the auspices of a UK mental health charity. These participants were either using the services of a mental health support group or affiliated with a mental health charity and differed in relation to marital status, age (between 30 and 65) and occupational background (customer service, admin and professional services in both public private and charity sectors). Voluntary participants (70%male/30%female) were experiencing one or more of the following conditions: depression, anxiety disorder (including OCD), bi-polar disorder or schizophrenia. Because of our narrower focus on identity in this paper, we selectively examine the open-ended interviews of only three of the participants who provided an intensive exemplification of the problems of an attachment to ‘normalized’ identities, although our other participants were not inconsistent with this analysis. Typical questions were ‘tell me about your work experiences in light of your MHC’; ‘How do you manage your MHC in the workplace’; ‘How do you deal with workplace/employer’s expectations’. Because of the sensitivity of the topic, we sought to impose as little as possible thus allowing participants to ‘openly’ discuss the experiences they found meaningful and about which they felt comfortable talking. Our analysis seeks to integrate both the ‘empirical’ material and certain ‘theoretical’ reflections within the research process (Alasuutari, 1995: 175).

The interview extracts were analysed inductively, and the themes emerged as we went back and forth between theory and the findings so as to provide an integrated analysis. The notion of ‘self-management’ refers to the participants’ intuitive or self-reflexive learning about, and support for, their MHC at work. These involved a range of practices including: regulated sleep patterns, mood dairies, diet, exercise, medication, talk therapy, self-help books, self-help groups, meditation and reflexivity in thinking, feeling and behaving. While manifesting themselves in different ways for each individual, they all pointed to the reflexive development of self-awareness, and new knowledge that enhanced self-learning of their condition and its management in the workplace.

Those reflexive practices are particularly important in the employment context as many of the participants addressed the interface between mental health management and employment as extremely challenging. Through the preceding stages of refining the analysis two key foci relating to self-management emerged: first, awareness of changes in their feelings, moods, thoughts, emotions and behaviours; and second, strategies for maintaining employment while also managing their MHC. Both of these were an expression of the participants’ reflexive engagement and self-learning about their MHC in the context of work.

A feature of the research was that Pete, James and Chris, alongside others in the study were interviewed at least twice and participated in a follow up meeting to discuss the overall findings in which they contributed their own further ideas. Through the email exchanges and the interviews, a relationship of trust and commitment to the study were established (Benton and Craib, 2001). This longitudinal stance also assisted in understanding how people reflect on their lived experiences over time and how their own learning helps them to craft their identities. Building on the assumptions that case examples can support the generation of rigorous data for theory development (Eisenhardt, 1989), the analysis seeks to enrich current theories of identity, especially in its relationship to learning and reflexivity.

Informed by our understandings of the participants in the empirical fieldwork, and by the insights drawn from theorizing the care for the self, the analysis is also strongly inspired by our own personal experiences of intimate associations with MHCs either of our own or others. For the first author, transient experiences of stress, anxiety, depression and ongoing repetitive thinking (common to many anxiety disorders), brought about an embodied insight on what it might have been like to experience these conditions long term. She utilized some of the insights on self-management evident in this research to help manage her own mental health during the time of the data collection and beyond. She also has long term experiences of providing care and witnessing MHC relapses within her immediate personal environment. In a professional capacity she previously worked as a researcher supporting NHS mental health commissioners and as an employment specialist for people with disabilities and MHCs – where she has assisted individuals wishing to make a full recovery and return to work. For the second author, the experience of a mental breakdown brought him to an embodied engagement with, and not just a cognitive understanding of, his attachment to a masculine identity. The cognitive understanding was insufficient to prevent the mental breakdown and while the medication perhaps stabilized him sufficiently not to be sectioned, only an embodied reflection on this attachment to identity provided him with the courage to abandon the psychiatric drugs and, although cold turkey withdrawal was exceedingly painful, it led to a permanent recovery. He also has experiences of MHCs at close hand in his personal relations with friends and relatives.

Identity as a performative effect of self-learning through caring for the self

The three vignettes ⁵ below point to the tension and challenge of keeping a working routine at the same time as managing an MHC – tensions that appeared to intensify in certain work settings and depended upon the self-care of the participants and their insight into their own condition.

The paint technician: Reflexive self-knowledge and emotional management

Recently married and in his mid-thirties, Pete has been working for a mid-size organization for the past 4 years as a paint technician. Pete’s account expresses his reflections of the tensions at work and he draws significantly on his own emotional and intellectual capital in learning to manage his MHC, as is reflected in this selection of quotes:

My biggest thing what I used to do is just not get sleep. I’d just go high as a kite and just get really ill. It wasn’t worth doing. Starting jobs and not finishing them, falling out with people because I was just out of my mind, you know. I was becoming more and more ill and I was losing touch with reality.

By reflecting on his past experience and gaining more insight into his MHC, Pete adopts new reflexive techniques to help him in learning to manage his mental health more effectively:

I realise about this disease: you got to be smart about it, you got to keep thinking. . .[For example,] . . . I tend to feel more down in the winter, so I think I pre-empted the winter and thought: “right I am going to get down feel myself coming down”. So, I doubled my medication, so I can feel less down, which is really great! I pretty much do it myself I can self-medicate pretty much which is ‘cos I know my condition.

Pete’s account illustrates how by reflecting and learning, he develops a set of expertise and self-knowledge for managing his own MHC and for maintaining a balanced routine and being in control over his own health condition. His account demonstrates the engagement with an empowered self: someone who is actively gaining a range of expertise and the self-understanding essential for effective management of his MHC. This latter point is especially relevant to Pete’s self-management in workplace settings.

Self-management at work: Disclosure and a sense of ‘normality’

The workplace is a complex and often problematic area for us all in managing the self but especially significant to those experiencing MHCs. The interview extracts indicate a variety of interventions through which the participants manage the interface between health, identity and work. Pete’s account illustrates this as well as some of the tensions that arise. Pete has a degree and wanted to join the royal armed forces. However, he adjusted his career plans because of his health condition. First, he began working as a teaching aide but found that this job triggered his MHC so, following a mental health episode, Pete decided to seek long term employment as a paint technician.

Although Pete feels ‘let down by the world of work generally speaking and I haven’t really found my niche’, he finds the work conducive in the management of his condition. His account illuminates how he manages his MHC through maintaining a balanced routine and ‘normalizing’ his identity:

I am happy where I am at the moment because if I could keep this without putting additional pressure on myself, . . . I think that maintaining stable is the fun bit. I always dreaded ‘being normal’. But I love it now that I understand the illness. I do see myself doing a normal job that is slightly beneath me cos I see it from the positive. I see it as something which I need to do and I don’t get down - that’s the important thing.

Although Pete struggled to fulfil his career ambitions, he equally finds that through different job experiences, he has learned to manage his MHC to remain well and secure the sense of a ‘normal’ identity through work.

He enjoys work and its social aspect: ‘I thrive off people and I won’t let this bi-polar get in the way, I won’t let it destroy me’.

On the one hand, Pete’s talk attests to his embrace of the MHC. On the other hand, the sense of ‘normality’ facilitates the self-management of his condition thus ‘not letting the MHC destroy’ his performative ability to maintain an identity of sociability and of employment. His account is a vivid demonstration of how self-care and the self-management of an MHC can stabilize the employment situation and possibly life more generally. Another example is Pete’s decision to disclose his MHC:

[In] that instance of being ill, I thought now I don’t want these people thinking I am some sort of funny you know or not someone who didn’t like to work you know. So, I wanted to be honest you know. I thought, I am sure people would like to help me if I had problems and you know.

While Pete is supported by his employer and colleagues, he equally argues: ‘actually they told me I was lucky to have a job because if I had told them [during the recruitment process] they might not have given me a job’, Pete’s disclosure was a performative act based on self-knowledge of his MHC and recognition of his need for a measure of colleague support simply to keep on top of the job. This support was helpful in maintaining some sense of balance in his working life: ‘there’re people there [who] would look out for me you know. Colleagues, managers are great’. However, he is convinced that prejudice prevails regarding him being potentially ‘work-shy’ and this had led him to disclose his condition so as to prevent him taking time off. Still, despite the support from his employer and colleagues, Pete felt vulnerable,

I don’t want there to be any prejudice and you know I am sure they have a laugh behind me because sometimes when I get down, my head is not really switched on and I am a bit slower than normal.

Revealing his MHC was partly to help him in his claim for a ‘normalized’ work identity as a morally responsible worker and reliable employee that avoids absenteeism or welfare dependency: ‘I have never claimed disability benefits’. At the same time, however, Pete’s disclosure also reflects the performative nature of identity as well as the duality between suffering and claiming recognition. While acknowledging that his condition can take a hold of him, Pete manages it largely so as to retain an active participation in the workplace but also to avoid his identity being stigmatized even further if he did not work, ‘I know that I am better off working and more independent’.

This way, he both manages his MHC but also engages in a performativity that has the effect of enabling his identity to appear ‘normal’. While Pete’s quest for normalcy is in and of itself extraordinary insofar as it needed excessive effort to manage his MHC and, also to compromise his preferred career path to sustain ‘normality’; he is ambivalent because work has fallen short of his expectations, ‘I am doing a normal job that is slightly beneath me’. Pete does not only feel vulnerable as a result of disclosing his condition, but he also tells the researcher two years after the second interview was conducted, that work was a struggle for him long-term as he felt that his MHC was not fully acknowledged by his employer.

Even when considering what is left when work seems to deny him much credibility, we can see how Pete embraces the positives of an MHC. Yet it also demonstrates his attachment to a ‘normalized’ work identity that extends beyond his present employment to an anticipated future, working in a more esteemed occupation as a writer or a journalist. However, he is conscious of how, for this to become possible, a great deal of care and management of the self is necessary:

I mean there are benefits there but you need to learn to control, to harness them. And that takes a lot of skill and a lot of insight to yourself so at the moment I am writing a lot . . . becoming a writer or a journalist will probably be my kind of ideal, it’s where I’d like to end, I suppose.

The architectural professional reflexive self-knowledge: Intuition, mental workout

James, a valued employee is an architectural professional in his mid-thirties and has worked for the same employer for the past eight years. Again, his account echoes a number of themes that were significant throughout the data set. He describes the management of his MHC as ‘harder than work or university but you are doing that in the same time’. He was perpetually engaged in self-disciplining practices:

When I was at my worst . . . I didn’t deal with it as a condition. I was dealing with it by myself in a sort of disciplined way, which is the worst way to deal with it because you sort of punishing yourself for your own condition. I wasn’t getting medical help or psychological help.

Since then, James has received some support through counselling and medication, but argues that his experience and self-awareness in living with the condition gave him far more insight:

I have dealt with it for so many years now I feel like I am an expert in what it is, what it feels like, what is obsessive, what is not obsessive and identifying what is probably is an obsession even if it feels very real. So, I am getting better at that all the time.

Through reflexive expertise and knowledge, James learnt how to self-manage manifestations of the condition:

I suffer from a huge mental disorder. Knowing that obsession is a very short thing, very intense thing, but the longer you can resist it the less intense it is. It’s a relentless having to do this because it keeps coming back because that’s I guess the way the brain is working. So, it’s hard not to react to which you have to just tell yourself - “just don’t react to it” ‘cos otherwise it just gets worse and worse.

James’s own reflection into his illness helped him identify more tools which he also adopted from other life settings. For instance, intuitively he has discovered that physical exercise helps in self-managing the MHC:

So basically, the way I manage things is accepting that it’s a mental workout, like [the physical one] in the gym you’re put in a sort of stressful position, you know it’s burning agony, but you know in the longer term you’ll see the benefits. You are doing it for a reason. So, I am employing that to my mental state. So, it’s not something I have had to learn: “this is how you deal with OCD”, it’s something I have had to trust and it’s kind of instinctive a bit more than learning a thing.

This shows that James’s self-management of his condition evolved instinctively rather from any medically recognized or externally learned format; a determination to recover combined with reflexive, self-learning enabled him to self-manage his MHC. This was developed through years of experience, self-awareness and an adaptation of different intuitive strategies, but his ‘normalized’ identity as a ‘committed worker’, performatively left him unaware of a disciplined dissembling of his MHC.

Self-management at work: Professional qualifications

James has struggled to accomplish the final part of his architectural training while working full time and admits that it is not ideal because of having to manage his MHC, but ‘it’s what I am good at’. Like many of our participants, through self-care, James manages his condition but simultaneously conceals it through hard work and commitment as part of performatively sustaining a ‘normalized’ identity:

I think the reason I am still in work is just sheer hard work ethic. I sear and overbear just overbear. Just absolutely I feel like working twice as hard as anyone else in the place to achieve the same level of output.

Although his employer is aware of his MHC, James avoids,

Showing weakness which, some people might see a condition like mine as. . .Times are tough, so your performance is constantly measured, we are all worried about our jobs so unfortunately, I conceal it [my MHC] and that makes it worse for me personally and psychologically.

His feelings of job-insecurity drive James to work at sustaining a ‘normalized’ identity as an employee without ‘weakness’ for, ‘You can’t keep banging on about it because people will get sick of it. Whatever is affecting performance potentially. . .You don’t want to appear the weakest link’.

Like Pete, James also seeks to meet the demands of the job without ‘banging on about’ his MHC to his employer, but this is not without some costs, one of which is that of delaying his studies for fear that the pressure would escalate his MHC further:

I have done most of the studying, but I am actually on sick leave from university. Because the OCD takes up so much of my time in work, I am stressed out, I get back and I have got to relax.

James’s insight and self-learning indicates to him that his MHC is a ‘chronic illness that you learn to manage but you don’t get cured’. However, when turning to his own identity work, James explains that his MHC is ‘such a big part of my life. . . and if I didn’t talk about it, my life would be a massive lie’. Yet, he neglects to do so at work because it might threaten his ‘normalized’ identity that he has worked so hard to secure and sustain. As with Pete, James’s account also demonstrates the extra-ordinary attempts that the participants put into maintaining a ‘normalized’ identity. Notwithstanding James’s attempts to hold on to this ‘normalized’ identity, he did in fact end up losing his job and, to this date, has not been back to work.

The IT consultant: Exceptional performance when being hypomanic

Chris was diagnosed with bi-polar in his late teens but then thrived both as a student and as a senior IT consultant working for a large health service provider until his mid-thirties when a mental health episode re-occurred. His account echoes the experiences of many of the participants in this research reflecting where the self-management of an MHC enabled an exceptional work performance partly enhanced by the hyperactivity of the condition. However, Chris’s effort to maintain a ‘normal’ identity, exacerbated by the hyperactivity, exceeded his ability to suppress the MHC, thus eventually resulting in interruptions of work. He reveals a lifestyle shared by many: ‘my work ethic was work as much as you can earn as much money as you can and go crazy on the weekend, you know, and live that sort of busy life-style – if you like – work hard, play hard.’

He explains how prior to becoming unwell he used to thrive on a hypomania-elevated mood which tended to manifest itself prior to having a full mental health episode:

When you are hypomanic at the bottom end scale you feel you have got lots of energy you are productive and sociable [but] there comes a point where it starts causing problems: It can increase to severe hypomania when you stop sleeping and stop eating and you speak and think very rapidly. I started to get more and more burnt out so rather than being very outgoing and sociable I started becoming more stressed, I would sleep four hours a night maybe. . .

Chris was unable to sustain this situation and partly because of struggling to explain his condition to his managers and colleagues, when becoming unwell, he felt there was no choice but to sever his employment:

I never disclosed to any employer that I have got health problems because they wouldn’t employ me, I have lied. Not lied but fabricated and being selective about the truth. . . it can be used against me in so many different ways. I will lose my credibility in my job and in the role that I have its very very important. If I start telling people I was bi-polar then it will be a problem

Chris explained how it took a number of months of him being unwell before telling his employer that he had ‘manic depression – that was after three month that was a very difficult thing to do’. Still, he tried to negotiate workplace accommodations but felt that ‘people were not agreeing with these reasonable adjustments and HR not being helpful at all’. From this point on, Chris’s life and work situation dramatically changed, and his focus shifted from responsibility to the corporation and work onto a radical care for the self.

Work, self-management and identity

Chris felt that ‘since I have been off work my confidence has destroyed my self-esteem, has destroyed my motivation to do anything, having any purpose in life, it’s just gone’. He started working part time in a local café while caring for himself and figuring out what to do next. However, this shift had a radical impact upon his identity:

I have gone from a position of a management consultant to work in a café. It does knock your sense of identity: I had a career a profession and you know that was good ‘cos it gives you a sort of standing in society and other people will judge you favourably on that. My sense of identity has been pretty much wrapped up in the job I had before and now, that’s gone. So, I have had to deal with that in that I have to try and appreciate myself for who I am and realize that anything I attached to or do is not a reflection of who I am. . . my perspective changed a lot and keeping yourself well and being happy is way more important than working. Yeah the focus in my life is not work anymore; it was before.

Here we can see that Chris had realized, what many in society do not, that an attachment to an identity is not exhaustive of what it is to be human. With this radical change came greater insights regarding his care and self-management:

I have improved a lot since I last saw you. . . I looked into so many treatments and therapies ‘cos I am not willing to accept that I’ll always be very ill, you know. I am sort of quite determined that I can help myself really. I don’t see my manic depression as an illness; I see it as a challenge when I try to get the best out of it really.

Chris is very enthusiastic over supporting the self-management of others and is both facilitating mental health management courses and evaluating them. Chris argues that he’ll ‘never work in a stressful job again: the consequences are-once you get to that position that’s a few years of your life gone’. He also draws upon his desire: ‘to put together a course for people with bipolar not just to self-manage but to explore the benefits of being bi-polar’. Having come to accept his condition, he abandoned playing the game of claiming a ‘normalized’ identity by putting, as the other participants did, extra ordinary efforts in keeping his job and identity as a successful IT consultant. Instead, teaching would bring benefits not only to others but also to himself for, as Chris argues, his MHC ‘does have lots of benefits’.

Like many experiencing MHCs, Chris was creative and perhaps over-committed to his work, eventually leading to his inability to continue. After some time doing what he sees as an undemanding job of working in a café, he has realized that his insights about MHCs can be mobilized to achieve what he considers a more worthwhile kind of work in helping others with a similar condition. This will, in his own terms, ‘normalize’ his identity as engaging in work compatible with self-managing his MHC and thereby, regaining the kind of respect from others that he has for himself. Reflecting our argument that attachments to, or preoccupations with, identity can be not only damaging but also counterproductive for those with MHCs as for us all, in his new commitment to teaching, Chris may however experience some of the same problems that previously forced him to leave his job as an IT consultant.

As authors who have also experienced work becoming stressful, we are aware that this was often to secure a ‘normalized’ identity as academics. For example, I (second author) left school at 16 and entered university later in life only to feel an ‘imposter’ (Knights and Clarke, 2014), always way behind everyone else and placing excessive pressure on myself to ‘catch up’ and work more intensively, occasionally to the point at which I was on the verge of experiencing an MHC. Indeed, this could have contributed to the condition reported earlier that I describe as stimulated by an attachment to a masculine identity since the latter often, as with Chris, is reflected in excessive demands on the self. Similarly, during my doctoral studies, I (first author) spent very long days struggling to keep on top of the work. ‘Putting in the hours’ and ‘meeting deadlines’, nodding to colleagues encouraging me to just ‘plug in’ often left me feeling overwhelmed, stressed, anxious, insecure, vulnerable as well as physically fatigued and with enduring musculoskeletal pain. Failing to meet deadlines was hardly ever considered an option, resulting eventually in a mental and physical state of exhaustion from which I took a long time to recover.

Discussion

This study has examined how people with MHCs engage in identity work through reflexivity, learning and self-care whilst simultaneously making extra-ordinary efforts to generate and sustain a ‘normalized’ identity to avoid being stigmatized. It also provided some insight into the lives of people with MHCs in the workplace by focusing on the performative effect of their identity work and self-management. Through deliberating on the questions we posed at the beginning of this article, the article offers three contributions to the field. First, we show empirically how individuals with MHCs engage with a range of reflexive and self-learned practices in order to manage their way through diverse circumstances at work.

Second, we illustrate theoretically how an interrogation of identity demonstrates the way in which an attachment to ‘normalized’ (but also any set of) identities might be counterproductive and self-defeating insofar as it deflects attention away from caring for the self. This contribution fills a lacuna in the literature in focusing on self-care as a way of learning about and managing identity (Brown, 2020). Third, in terms of practice, we suggest that any attachment to particular identities is problematic especially for those with MHCs who seek ‘normalization’ as opposed to embracing difference. This is an important understanding for individuals with MHCs and possibly mental health practitioners but also could assist managers in organizations where they are employed.

In relation to the first contribution, we provided empirical evidence to show how learning to care for the self may facilitate a certain freedom of agency, albeit not always under conditions of our participants’ own choosing. This may take the form of performative strategies (Butler, 1993) of disclosing or dissembling depending on whether a revealed or concealed MHC is deemed effective or not in sustaining a particular identity of ‘normality’ (Corrigan and Matthews, 2003). These performative strategies reflected our participants’ learning from their organization how best to manage their ‘normalized’ identity in the context of the expected presence or absence of support from their managers. Caring for the self is an empowering practice (Randall and Munro, 2010) providing a platform from which our participants first and foremost, could retain an employed status and secondly, choose whether or not to disclose their MHCs.

While their learned agency was positive for job security, the pressure of presenting themselves as ‘normal’ did often result in a self-reproducing downward spiral of negative MHC symptoms. Nonetheless, our participants expressed a vigilance in learning to avoid this downward spiral. Occasionally, as in Chris’s case, the energy and effort involved in sustaining a ‘normalized’ identity overwhelmed him leading to a departure from work and a reflexive reassessment of the self-care and management of his condition. Overall, this first contribution identifies how self-knowledge assists individuals in finding creative ways to ‘normalize’ their identity at work (Crozier and Woolnough, 2020) or alternatively how learning about the self enables a more radical care of the self.

In terms of the second contribution, our exploration goes beyond the tendency to take identity for granted as an unquestionable value and suggests how becoming attached to it as a source of social significance, stability and security can be damaging for those with MHCs. This is not to deny the desire for a stable identity nor to believe it could or should be eliminated but it is to question the tendency for people generally to become excessively attached to it. Such attachments can be seen as an invidious strategy in ‘the government of individualization’, forcing us back on ourselves to become ‘tied . . . [to our own] . . . identity in a constraining way’ (Foucault, 1982: 781 orig. emphasis). The valorization of identity is not just prevalent in academic research (Brown, 2015: 21, 2020) for it also pervades the media, politics and everyday life where there is endless talk about who I am or wish to become. In becoming attached to a particular identity, invariably attention is turned to rendering it secure and stable – a difficult if not impossible project given the dependence of any identity on others’ affirmations that cannot be anticipated, let alone controlled (Knights, 2021).

In the context of MHCs, however, the attachment to a ‘normalized’ identity, as alluded to in our findings, can result in a self-induced, normatively-driven work intensification that, in many instances, deflects attention from caring for the self as has been recognized in relation to other disabilities (Fevre et al., 2013). While we are critical of contemporary preoccupations with identity (Collinson, 2003: 532–533) that verge on narcissism (Crevani and Hallin, 2017), this does not mean that individuals, groups organizations or institutions are deprived of their agency in managing identity. As we saw in our vignettes, there are limits not only in terms of unintended consequences but also agency is bound by the necessary reiteration of norms that constitute and constrain performative enactments of identity (Butler, 1993).

Given that identity is little more than an assemblage generated through our sense of others’ social confirmations of what we are (Mead, 1934), caring for the self is as much about others as oneself (Foucault, 1988), albeit often distorted through the constraints of ‘an individuality that has been imposed on us’ (Foucault, 1982: 216). This is reinforced by the values of individual self-interest perpetrated by the market relations of neo-liberalism. It is this individualization that prevails on us to become attached to particular identities that, in the case of our participants’ desire for acceptance as ‘normal’, became increasingly difficult to sustain. Ultimately, this undermined the practices of caring for themselves, resulting in an exacerbation of their MHCs.

Our participants were engaged in this kind of self-care, self-management and reflexive learning to think differently about their difference so as to resist the stigmatized identity of their condition and retain stable employment. In this resistance, however, they remained attached to a ‘normalized identity’ which can be equally as oppressive, stressful and precarious for, like all identities, it is fragile and forever in danger of erosion which is problematic for all workers (Corlett et al., 2019), but especially for those with MHCs. For while care for the self is important in avoiding uncontrollable breakdowns, becoming attached to a ‘normalized’ identity is problematic since ‘normalization’ often displaces practices of caring for the self, along with its benefits an important part of which is, at least, acknowledging, if not celebrating, one’s difference. This occurred with our participants particularly when their MHC became overpowering partly due to their attachment to a ‘normalized’ identity. While we would refrain from the non-politically correct way in which Foucault (1961: 23) asserts that ‘self-attachment is the first sign of madness’, we wholly endorse the problematizing of any attachment to identity (Knights and Clarke, 2017).

It requires a further stage of interrogation to reflect upon how an attachment to identity can reinforce, rather than transform, an MHC. Temporarily, a ‘normalized’ identity can protect against stigma and provide some security of employment, but it is risky insofar as it leaves the individual vulnerable to the pressures of work intensification and other management expectations. Consequently, our participants protected their jobs in the short term by displaying the relative stability of a ‘normalized’ identity but this meant concealing the condition in ways that readily came back to ‘bite’ them as they sought to meet the excessive demands and expectations of their managers. Either compliance with or resistance to these demands had the potential to exacerbate the MHC to the point at which a ‘normalized’ identity became no longer an option as a means of maintaining their employment.

In our research, the attachment to a ‘normalized’ identity was counterproductive insofar as it displaced the potential of our participants to care for themselves as their energy was then deflected on to meeting the demands and expectations of ‘normality’ which often involved excessive work intensification. Chris’s attachment to a high-profile professional identity for example, resulted in him becoming a consultant resulting in a great deal of stress that led eventually to long periods of illness. His text indicated a certain level of agency in his withdrawal from the corporate world but his attachment to professionalism certainly backfired. Although to our knowledge, there is paucity of research exploring how attachments to identity may have negative unintended consequences, an exception is the examination of the professional identities of a range of managers (Corlett et al., 2019). While some of the managers which were studied by Corlett et al. (2019) were defensive regarding their professional identities for fear of expressing any vulnerability, one participant was selected as offering an alternative to illustrate vulnerability as a potential ‘strength rather than weakness, and as relational and emotional openness rather than defensiveness’ (p. 570). In our vignettes, sharing their MHC vulnerabilities offered similar learning possibilities with support from colleagues but, fear of the consequences for their jobs was often discounted as an option in favour of ‘normalization’.

Consequently, interrogating identity is not just a theoretical exercise, for practically, it is potentially self-revelatory in facilitating an understanding that may help alleviate suffering in a range of working contexts. This reflects the third contribution of our analysis where we think it has certain practical implications for management and organizations in providing insights that might encourage support for, and possibly help to diminish, the severity of the experience for those with an MHC in employment. Often our participants declared their dissembling to be necessary because of bosses who were unsympathetic to any problems that might arise for those experiencing MHCs.

While there is some literature on stigma resistance for MHCs (Anspach, 1979; Thoits, 2016) and although the HR departments in organizations often provide guidance and training programmes for equal opportunity and anti-discrimination (Rumens, 2017), there is insufficient attention given to MHCs (Martin et al., 2015). This research throws light upon how engagement with learning to self-manage a health condition at work can help to prevent its escalation in unproductive ways. However, it also demonstrates some of the unintended consequences of the ‘identity’ processes when ‘normalizing’ an MHC results in unsustainable levels of performativity in response to excessive management demands and expectations. The consequences of expressing vulnerability through disclosure was unpredictable and, based upon responses from colleagues or managers, participants were continually learning if, when and how to display their MHC in order to avoid negative outcomes (Gonzalez et al., 2020). Our research could sensitize managers, health professionals and educators to the potential positive and negative benefits of practices of self-care. For, whether in the form of employees concealing or revealing their own MHC, or through forms of self-knowledge and individual intuitive learning, self-care is an important learning device for treatment and training programmes. Importantly, this can also provide a fuller understanding of how MHCs are experienced and managed to enable individuals to hold on to their work in a way that does not compromises their health. At the same time, our analysis suggests that everyone involved, including employers themselves, could benefit from an awareness of the limits to pursuing a ‘normalized’ identity.

Conclusion

Our analysis throughout the paper has sought to integrate the empirical evidence of the participants seeking to manage their condition through ‘fitting in’, maintaining stability, concealing their condition or what we have described as a process of ‘normalizing’ their identity. This has been theorized in terms of their attachment to this identity of ‘normality’ that then can deflect attention from and the benefits of caring for the self, resulting in more severe episodes of their MHC. We have seen how those with MHCs learn to manage and care for themselves in ways that embrace, rather than just accommodate, their difference and difficulties. It demonstrates how those who ‘start off’ as non-normal and deviant or what is stigmatized as ‘mental illness’ deploy extraordinary resources of self-care to become ‘normal’ through working on the self while at work. There is no doubt that learning can help transform circumstances through acts of self-care which then improve the living conditions of individuals in a neoliberal culture that often fails to accommodate diversity and especially the problematic experiences of employees with MHCs (Fevre et al., 2013).

However, these exemplary employees who work on themselves in a vigilant way as knowledgeable about their own condition, demonstrated the limits of the enterprising self or neo-liberal subject in moulding a self to meet work demands. They were intent on advancing a ‘normalized’ identity and sometimes at considerable personal cost especially, in Chris’s case, where it was disruptive before he realized that this was becoming as much the problem as the solution to his MHC.

Summing up the contributions, our participants were seeking to ‘normalize’ their identities as part of a strategy to maintain themselves in employment – a status that also conveys an identity to which many were attached, not surprisingly given that a job is concerned with material and not just symbolic, survival. They did this largely by caring for themselves – something learned through a self-reflexive understanding of their condition – by intervening to prevent exposure to breaches of ‘normality’ that would lead to them being stigmatized. However, this had some unintended costs since it often involved concealing their MHC as a way of maintaining a normalized identity and, on occasion, this returned to haunt them especially when struggling to meet the excessive performative demands of their employment.

We are conscious of the limitations of the research in relying principally on interviews and, in this article, a focus only on three illustrative vignettes from a much larger data set. A further limitation is our concentration on those experiencing MHCs when the organization, and its performative demands in an intensification of work, also has a major responsibility for the perpetuation of their condition. While this limitation is perhaps a weakenss of the research design, the focus on identity is illuminating and fits with the scope and aims of this special issue, and further research could consider more directly the organizational pressures of work intensification that are damaging to the mental health of all workers but especially those already exposed to an MHC.

Our exploration of the potential counterproductive aspects of identity work may be of value not only to those experiencing MHCs but also management practitioners and health professionals. For in intensifying their attempts to normalize identity, we have found that employees with MHCs may exacerbate their condition thus rendering them less valuable to the work organization. By implicitly or explicitly collaborating with employees with MHCs in their quest for a normalized identity, management and professionals generate unintended consequences, such as long-term absenteeism, that are damaging for all concerned (CIPD, 2020). If employers were to think differently especially about difference or at least comply with the spirit and not just the letter of the law (Hoque et al., 2014; Hoque and Noon, 2004), they would offer employees with MHCs job security, status as well as an ethical acceptance of their difference. This would reduce the damaging consequences for employees with MHCs of attaching themselves to a ‘normalized’ identity. For this ‘normalization’ can become as difficult to manage as the MHC itself. Under conditions of work intensification, either self-induced or driven by management, attachment to a ‘normalized’ identity readily exacerbates an MHC. As such, a failure to interrogate the downside of identity work has wider implications than just what it means for those with MHCs.

As MHCs have been rising in contemporary society, and perhaps deepened by the Covid pandemic, it may become even more important for future studies to develop this analysis of learning to care for the self at work. Indeed, we agree that questioning work itself and not just people with MHCs is highly significant. Work intensification and the competitive demands placed upon employees in neoliberal market economies can impact negatively on everyone, although particularly badly on those with disabilities or MHCs who may then suffer further marginalization (Pacheco et al., 2014). Analysis of this nature could complement and extend our research to illustrate the challenges for us all in managing our identity within the context of employment constraints and the struggles of many to deal with less than ‘perfect’ mental/emotional adjustments at work.