I do not expect much ikigai from work : A failed link between employment and well-being among adults with serious mental illness

Abstract

BACKGROUND:

Researchers argue that employment positively affects the well-being of people with serious mental illness. However, empirical studies have provided limited support for these hypotheses.

OBJECTIVE:

This study aimed to investigate perceptions of employment in relation to the meaning and purpose of life, an important aspect of well-being, among people with serious mental illness.

METHOD:

Qualitative research design was employed. Psychiatric service users with a history of employment (n = 21) were recruited from Japan. Photo-elicitation interviews were conducted, and the interview data were analyzed using thematic analysis.

RESULTS:

Employment was recognized as a source of life meaning and purpose when it reflected personal values such as mastery and contribution to society. Employment was not recognized as relevant to life’s meaning and purpose if it was regarded as an instrumental activity for making a living. Nevertheless, participants generally agreed that employment was indispensable because it was essential for fulfilling their basic needs and overcoming the stigma of mental illness.

CONCLUSION:

Our results demonstrate diverse attitudes toward employment among people with serious mental illness, which may explain why employment had only a small effect on well-being.

Keywords

Employment work quality of life mental disorders

1 Introduction

The well-being of psychiatric patients is an important outcome of psychiatric services (Clarke et al., 2012; Krupa et al., 2020). Researchers have argued that employment has a positive effect on well-being among people with serious mental illness (Drake & Wallach, 2020; Walsh et al., 2012) because employment has positive meanings to this population (Dunn et al., 2008; Khan & Boardman, 2017; McKee-Ryan et al., 2005; Piltch, 2016; Rueda et al., 2016). For example, employment can signify recovery as it involves returning to a valued social activity (Axiotidou et al., 2021; Dunn et al., 2008; Millner et al., 2022). Employment is also associated with greater independence and self-esteem as it provides a means of financial security (Dunn et al., 2008; Millner et al., 2022; Piltch, 2016; Rosso et al., 2010). Furthermore, employment can provide opportunities for growth and self-actualization (Millner et al., 2022; Walsh et al., 2012). However, recent meta-analyses showed the effect size of employment on well-being is small (Cohen’s ds = 0.28–0.34; Frederick & Vanderweele, 2019; Wallstroem et al., 2021; van Rijn et al., 2016). It is unclear why employment has only a small effect on well-being. This lack of knowledge prevents psychiatric service researchers and practitioners from creating employment assistance programs that are effective in enhancing patientwell-being.

One important aspect of well-being that has been understudied is life’s meaning and purpose (Browne et al., 2017; Slade, 2010). While vocational rehabilitation researchers argue that employment has an inherently positive meaning for people with serious mental illness (e.g., Millner et al., 2022), it is unlikely that all employment is perceived in such a way. One possible factor is negative experiences related to employment participation, such as being given menial jobs or not being given opportunities to establish relationships with colleagues (Diby et al., 2021; Saavedra et al., 2016). Another potential factor is diversity of work values. In the general population, some people do not see employment as a venue for self-actualization (Krahn & Galambos, 2014). Even among people with serious mental illness, Krupa and colleagues (2020) questioned work as the sole source of their life meaning and purpose and encouraged the field to explore other alternative activities. Although some progressive arguments exist, the diversity in work values among people with serious mental illness has rarely been examined.

Perhaps investigating how people with serious mental illness perceive the relationship between employment and life meaning and purpose may provide clues to answer the question of why employment has only a small effect on well-being. Hence, this study aimed to explore perceptions of employment in relation to meaning and purpose in life among people with serious mental illness. In this context, we conducted a qualitative inquiry with Japanese adults with serious mental illness with a focus on the Japanese concept called ikigai, the word that is often translated as “life worth living” or “reasons for living” (Kumano, 2018; Mathews, 1996). Kumano (2012) held that ikigai is a multifaceted construct that encompasses life affirmation, existential value, and meaning in life. Kamiya (1996) posited that the characteristics of an activity that make something a viable source of ikigai possess value beyond instrumentality. Due to its cultural nuances, researchers argue that no single English word exists to capture the entirety of ikigai concept (Lomas, 2016). However, researchers typically understand ikigai as compatible with life’s meaning and purpose (Fido et al., 2020; Kumano, 2018; Lomas, 2016). The concept of ikigai includes the feeling of meaning and purpose in life, and describes an activity that evokes feelings of meaning and purpose (Kamiya, 1996; Kumano, 2018).

In the context of its income policy and occupational culture, Japan maintains a social security system aimed at shielding its socially vulnerable demographics. Although the social safety net program potentially mitigates the proliferation of homelessness, as noted by Kasai et al. (2018), it has proven insufficient, leading to an increase in income inequality (An & Asao, 2023). Furthermore, studies on stigma frequently highlight the prevalent misconceptions and negative attitudes toward mental illness among employees in Japanese corporate settings (Ottewell, 2019; Lem et al., 2023). This suggests that the Japanese labor milieu may harbor pessimistic perceptions of employment among individuals with mental illness.

Japan ratified the International Labor Organization Convention of 1992, which involved vocational rehabilitation and employment for people with disabilities. Based on ratification, domestic laws were established to support the employment of people with psychiatric disabilities (Kurachi, 2015). In 2006, the Japanese Congress established the Services and Support for Persons with Disabilities Act. The employment support system provides sheltered workshop and employment transition services. With the recent inclusion of people with psychiatric disabilities in the statutory rate of disabled employees, an increasing number of people with psychiatric disabilities have been employed (Kurachi, 2015). Employment is considered an important part of the psychiatric services in Japan (Hayashi et al., 2020) and is often promoted as an activity associated with ikigai (Sakai & Mizuno, 2011).

In terms of the meaning of employment in Japan, Yoneda (2021) reported that Japanese people do not perceive work as much as they did a couple of decades ago; in fact, the current level of work centrality is similar to that of other developed nations. Still, among the Japanese, employment and marriage are perceived as the attainment of adulthood (Cook, 2013). These studies show that while an increasing number of Japanese people consider employment instrumental, it is still considered essential in Japanese culture. Furthermore, there is no literature on how people with serious mental illnesses perceive the relationship between employment and ikigai. Thus, the research question of the current study was, “how do people with a serious mental illness perceive employment in relation to ikigai?”

2 Methods

2.1 Study design and setting

This study was part of a larger qualitative research project on ikigai among people with serious mental illness. We conducted qualitative interviews with people with serious mental illness in Japan between April and December 2022. We used thematic analysis, an interpretive approach, to understand how our interviewees construed the meaning of employment and its relationship with well-being (Braun & Clarke, 2021). The findings were reported based on Journal Article Reporting Standards for Qualitative Research (Levitt et al., 2018).

2.2 Study sample

Purposeful sampling was performed to obtain the target population. Participants were recruited from nine social welfare or community service agencies across Japan, including clubhouses, daycare services, group homes, and community support centers. Inclusion criteria were 18 years old or older and having a diagnosis of schizophrenia spectrum disorder, bipolar disorder, or major depressive disorder. Service agency representatives identified service users who met the inclusion criteria and expressed interest in the study. The lead author met with the individuals and obtained informed consent. The study protocol was approved by the Institute of Health and Sport Sciences Institutional Review Board at University of Tsukuba.

Twenty-two individuals participated in the overall study, and the current study is based on our analysis of data from 21 participants who had a history of employment. The average age was 46.52±11.43 years, and 38% identifying as female (n = 8). The primary diagnoses were schizophrenia spectrum disorder (n = 12; 57.1%), major depressive disorder (n = 5; 23.8%), and bipolar disorder (n = 4; 19.0%). Seven participants (33.3%) were employed at the time of the study, five (23.8%) were in a sheltered workshop, and nine were unemployed (n = 9, 42.9%) with past employment experiences.

2.3 Data collection

We used the photo-elicitation interview method (Tinkler, 2013). This method facilitates participants’ reflections on the interview topic and allows them to discuss abstract subjects such as ikigai with more clarity and confidence (Tinkler, 2013). Participants collected 10 pictures (either choosing from pictures they had or taking new pictures) that represented their ikigai, and wrote notes regarding each picture’s relevance to ikigai. We did not specifically ask participants to collect photos of employment because we assumed that this could lead to richer data. If a work-related photo was included, it was considered a naturally emerging genuine ikigai for the participant. However, when a work-related photo was not included, participants could discuss why work was not associated with their ikigai, using their other ikigai photos as reference points. After submitting pictures and notes to the first author, semi-structured interviews were conducted with each participant. The interview questions included: “What exactly in the picture did you think related to your ikigai?” “What do you think of work and ikigai?” and “How do you think you can improve your ikigai?” The interviews lasted for an average of 80 minutes, ranging from 63 to 105 minutes.

2.4 Data analysis

Interview transcripts were used for data analysis. Interview recordings were transcribed verbatim by professional transcribers in Japan, and the first author reviewed their accuracy. We followed Braun and Clarke’s (2021) thematic analysis approach. The first author familiarized himself with the narratives by reading all the transcripts twice. Notes were taken while reading, and initial codes were developed. He then conducted inductive coding of the transcripts with the support of NVivo, creating new codes as needed. After all interview transcripts were coded, the first author developed relationships among the codes and identified broader themes. For the sake of trustworthiness, the second and third authors, who are experts in supported employment and meaning in life, respectively, conducted a peer debriefing by reviewing candidate themes, their descriptions, and supporting quotations. Based on their feedback, the first author refined the themes further. Peer debriefing was repeated three times until the authors agreed on the themes. These quotes were translated into English when the manuscript was written. The first author translated the original Japanese quotes into English, and three co-authors checked the accuracy of the translation.

3 Results

The thematic analysis generated three themes: (a) doing what they believe is valuable – a link with meaning and purpose; (b) employment being an activity that is unrelated to personal values – a failed link with meaning and purpose; and (c) the indispensability of employment. These themes demonstrate that whether employment reflects personal values determines the relationship between employment and meaning and purpose of life. Nevertheless, even those who did not recognize employment as a source of meaning and purpose agreed that it was vital to their lives (Fig. 1). Table 1 summarizes the themes and the selected quotations.

Fig. 1

Developed themes from the interview data.

Table 1

Participant perception about employment in relation to ikigai, or life meaning and purpose

Theme and subtheme	Selected quotations
Doing what they believe valuable – a link with meaning and purpose
Acting upon self-oriented values	“I sometimes tell people that I would like to work in music or writing. . . . I am doing one of them now. So, that is why my work is my ikigai.” (015)
	“As I said before, it’s (my ikigai is) work. I have nothing else I can do, and I am not good at academics.... I learn about work and think about how I improve it. I enjoy working while thinking about it.” (009)
Contribution to others	“I make a part of a car. It is only a small part of the whole car, but still, we cannot build a car if I do not make it (the part). . . . And by doing the work, I was able to feel the meaning of my existence.” (023)
	“If I were healthy and working, I thought that my ikigai would be to connect with society, or connections through work. But I have a disability and I cannot work. Well, I don’t think I have as much ikigai as most people do.” (007)
Employment being an activity that is unrelated to personal values – A failed link with meaning and purpose
Employment as merely a means to earn money	“It’s (My ikigai is) not work. My job is a way to earn money.” (020)
	“Since I became ill, to be honest, I cared little about what kind of work I do to earn money.” (006)
	“Well, rather than thinking of work as my ikigai, I only thought of it to earn money. Well, of course I enjoy it, but I would say that hanging out with my friends at work is more like my ikigai.” (003)
Non-work activities as sources of ikigai	“I do not expect much (ikigai) from work because I have theater, Haiku, and writing.” (006)
	“If you say that work is your ikigai, resting and playing are simply to restore energy so that you can work hard. I think it’s the opposite, in a sense, resting and playing give me something to live for. . . . I don’t really feel that work is my ikigai. I don’t think I live for it. I want to work hard at my job, but the moments when I refresh myself are the moments that I feel ikigai.” (014)
Indispensability of employment
Earned income to provide for basic needs in life	“Although losing employment does not kill you, you really shouldn’t lose employmentYou can’t lack it, because you have to earn money.” (017)
	“I think everyone thinks that if you don’t work, you can’t eat. . . . If you don’t work, however, you cannot have what you want, you cannot eat what you want to eat, or you cannot do your hobbies.” (009)
	“(Employment) is important, or rather, everyone works. I think that money is also necessary for daily living.” (002)
	“When I first joined futsal, I didn’t have quite enough money to buy a futsal ball... When I was able to buy one, I was really, really happy.” (005)
Approving themselves and gaining approval from others	“If I didn’t work, well, it is like denying the life I have led so far. Now, I can affirm myself because I work and earn money.” (015)
	“I single-mindedly pursued employment because things like discrimination, or the differences between me and the people around me was a barrier for me. So, to remove that, I thought I had to do the same kind of work they do. Otherwise, they wouldn’t recognize me.” (004)
	“I am so self-denying that I could not keep my job.” (002)
	“If you have a mental illness, work becomes even more important than it is for ordinary people. . . . I think it is good that you can consciously affirm yourself.” (015)

3.1 Doing what they believe is valuable – A link with meaning and purpose

This theme explains why employment improves meaning and purpose in life. We identified two subthemes: (a) acting upon self-oriented values and (b) contributing to others. This theme demonstrates that if their employment embodies their personal or cultural values, it can be ikigai.

Some participants’ narratives of ikigai involved activities deemed important by individuals. “I sometimes told people that I would like to work in music or writing. . . . I am doing one of them now. So, that is why my work is my ikigai” (Participant 15; competitive employment). As they engage in such activity, they seek mastery: “As I said before, it’s (my ikigai is) work. I have nothing else I can do, and I am not good at academics.... I learn about work and think about how I improve it. I enjoy working while thinking about it” (Participant 9; competitive employment).

Others mentioned that what they did at work contributed to something larger than themselves. Participant 23, who worked at a sheltered workshop stated, “I make a part of a car. It is only a small part of the whole car, but still, we cannot build a car if I do not make it (the part). . . . And by doing the work, I was able to feel the meaning of my existence.” Similarly, Participant 7, who were unemployed at the time of interview mentioned: “If I were healthy and working, I thought that my ikigai would be to connect with society, or connections through work. But I have a disability and I cannot work. Well, I don’t think I have as much ikigai as most people do.”

3.2 Employment being an activity that is unrelated to personal values – A failed link with meaning and purpose

This theme explains why employment is not linked to the meaning and purpose of life. This theme consists of two subthemes: (a) employment as merely a means to earn money and (b) non-work activities as sources of ikigai. This theme demonstrated that employment does not reflect their values.

Some participants bluntly said, “Well, talking about ikigai, well, employment was not my ikigai” (Participant 4; previously had competitive employment but was unemployed at the time of the interview). Rather, these people identified employment as merely a means to earn money: “Well, rather than thinking of work as my ikigai, I only thought of it to earn money” (Participant 3; competitive employment). Participants do not seem to associate work content with their well-being: “Since I became ill, to be honest, I cared little about what kind of work I do to earn money” (Participant 6; competitive employment).

These participants typically claimed that other non-work activities were sources of well-being. Participant 3 maintained competitive employment and said, “Well, of course I enjoy it (working), but I would say that hanging out with my friends at work is more like my ikigai.” It is not that they do not see value in employment; rather, they identify nonwork activities as sources of well-being. Participant 14, who maintained competitive employment, reported:

If you say that work is your ikigai, resting and playing are simply to restore energy so that you can work hard. I think it’s the opposite, in a sense, resting and playing give me something to live for. . . . I don’t really feel that work is my ikigai. I don’t think I live for it. I want to work hard at my job, but the moments when I refresh myself are the moments that I feel ikigai.

Participant 6 who maintains a competitive employment, for example, engage in serious amateur pursuits such as theater play and writing as well as Haiku, the Japanese poem: “I do not expect much (ikigai) from work because I have theater, Haiku, and writing.” When such serious engagement in amateur pursuit is recognized as a major source of life meaning and purpose, employment is not seen as a source of life meaning and purpose.

3.3 The indispensability of employment

Regardless of the link between meaning and purpose, the participants generally perceived employment as indispensable to their lives. The reasons behind this perception were identified as two subthemes: (a) earned income to provide for basic needs in life and (b) approving themselves and gaining approval from others.

Earning income was seen as essential as participants said: “Although losing employment does not kill you, you really shouldn’t lose employment. You can’t lack it, because you have to earn money” (Participant 14; sheltered workshop). Participant 9, who maintained a competitive employment, also shared their internalized belief regarding employment indispensability: “I think everyone thinks that if you don’t work, you can’t eat. . . . If you don’t work, you cannot have what you want, you cannot eat what you want to eat, or you cannot do your hobbies.” Thus, the participants associated income earned through work with meeting their basic needs.

Another common reason that work is indispensable is that employment can help participants gain approval from others and facilitate their self-acceptance because it can make them feel that they are equal to those who do not have a mental illness. Participants believed that being employed put themselves in a good light: “If I didn’t work, well, it is like denying the life I have led so far. Now, I can affirm myself because I work and earn money” (Participant 12; competitive employment). In addition, participants identified employment as an activity that other people recognized as valuable.

I single-mindedly pursued employment because things like discrimination, or the differences between me and the people around me was a barrier for me. So, to remove that, I thought I had to do the same kind of work they do. Otherwise, they wouldn’t recognize me. (Participant 4 previously had competitive employment but was unemployed at the time of the interview.)

Participants considered employment, or lack thereof, as something that separated them from those without mental illness. They believed that to be equal, they needed to be employed.

4 Discussion

This study aimed to explore how people with serious mental illness perceive work in relation to meaning and purpose– an important aspect of well-being– via the corresponding Japanese concept of ikigai. We found that employment can lead to an experience of life’s meaning and purpose if the activity reflects one’s values. However, if employment was perceived as merely an instrumental activity without relevance to their values, they would not associate employment with life’s meaning and purpose. Our data demonstrated that personal values are factors that determine the link between life meaning and purpose, which can possibly explain why employment had only a small effect on well-being (Frederick & Vanderweele, 2019; Wallstroem et al., 2021; van Rijn et al., 2016) because not all of them derive life meaning and purpose from employment. This new knowledge is novel because previous studies on the employment of people with serious mental illness, including qualitative meta-analyses, have never decoupled employment and well-being (Axiotidou et al., 2021; Drake & Wallach, 2020; Millner et al., 2022; Walsh et al., 2012).

When employment is not considered a source of meaning and purpose in life, people’s attitudes toward employment are purely instrumental, claiming that employment is merely a means to earn money. While this finding might be unexpected, such an attitude toward employment has been documented among the general population (Krahn & Galambos, 2014). A common reason reported by the participants was that they engaged in other activities linked to their life’s meaning and purpose. This finding supports Krupa et al.’s (2020) criticism of the belief among some psychiatric service providers that employment is the sole source of meaning and purpose in life. This is also in line with the extant research on decreasing work centrality among the Japanese (Yoneda, 2021) and with employment being only one of the many sources of ikigai (Kono & Nagata, 2021). As attitudes toward employment have diversified among the general population, diverse views on employment among vocational rehabilitation patients should be acknowledged and welcomed.

In contrast, employment leads to an enhanced meaning and purpose of life if it reflects their values. These individuals typically regard employment as meaning beyond earning income. One aspect of this is self-oriented values, such as employment, which are perceived as opportunities for growth and self-actualization (Millner et al., 2022; Walsh et al., 2012). The other aspect is altruistic values such as employment, perceived as an opportunity to contribute to society (Millner et al., 2022; Steger, 2019). The emphasis on contribution to society might be because of the collectivistic Japanese culture, where contributions to achieving collective goals are expected (Miller & Kanazawa, 2000). Employment is perceived as an intrinsically motivating and meaningful activity. Research has shown that intrinsic motivation and meaningful activities can enhance well-being (Allan et al., 2019; Ryan et al., 2008). It is speculated that for these individuals, a notable degree of employment effect on well-being should be observed.

Another major finding that may provide nuance was that, even if employment was not directly linked with their life meaning and purpose, they generally perceived employment as indispensable. For people with serious mental illness, employment is a particularly important activity for meeting their basic needs, such as financial independence (Torres-Stone et al., 2018) and overcoming poverty (Sylvestre et al., 2018). This is important because they may not be able to engage in meaningful nonwork activities without financial independence. Employment is associated with approving of oneself and gaining recognition from others. Disability, particularly ones that are considered invisible (e.g., mental illness and developmental disabilities), carries great stigma in Japan, and people with disabilities often feels ‘less than’ (Kasahara-Kiritani et al., 2018). Perhaps, they feel employment is indispensable because employment can make them feel ‘normal,’ just like everyone else who do not have a disability (Brouwers et al., 2023; Walsh et al., 2012). In contrast, being unemployed and having a mental illness can result in greater internalized stigma (Staiger et al., 2018) and compromised self-esteem (Brouwers et al., 2023), which can compromise meaning and purpose in life. Considering the contexts surrounding disability, employment may play an important role in maintaining the meaning and purpose of life; thus, it is considered indispensable.

4.1 Implications

Our findings have several implications for vocational rehabilitation service providers. First, it is important for practitioners to understand how each client perceives employment, and particularly, whether employment reflects their personal values. Practitioners should be aware of individual employment needs and adjust services while respecting personal views. For people who perceive work as a pathway for their self-actualization, practitioners should support finding employment where they can experience mastery as well as a sense of contributing to society.

For those who consider employment an instrumental activity to make a living, perhaps the choice of employment might be somewhere where they can reserve energy for other non-work activities that might be their source of meaning and purpose. While these patients can be misjudged as having low motivation to work, they are likely to perceive employment as indispensable for meeting their basic needs and overcoming the stigma of disability. Furthermore, as the participants mentioned, new friendships may develop with colleagues in their employment, which could potentially enhance their engagement in meaningful non-work activities. Thus, employment assistance is essential to meet the patients’ needs.

4.2 Limitations

Although this study offers novel insights, a few limitations should be acknowledged. First, as the study only included people who used community psychiatric services, our findings may not be generalizable to those who did not receive community psychiatric services. Although the generalizability of the findings may be an issue, our data may reflect the patient population encountered by psychiatric service providers. Another limitation was the difference in the employment status of the participants. For example, participants who were unemployed at the time of data collection may have reported an amplified desire to return to work, resulting in a positively biased perspective on employment. However, those who are employed may also report a negative perspective on employment if they face personal conflicts or are underpaid. Including both employed and unemployed individuals may have made our findings more insightful.

5 Conclusion

The current study investigated how employment leads to meaning and purpose in life among people with serious mental illness. Employment is recognized as a source of meaning and purpose in life when it reflects personal values, such as mastery and contribution to society. In contrast, employment was not recognized as relevant to the meaning and purpose of life if it was regarded as an instrumental activity for making a living. Our results demonstrate diverse attitudes toward employment among people with serious mental illness, which might explain why employment had only a small effect on well-being in previous meta-analyses. Nevertheless, employment was considered indispensable even for those who did not associate employment with the meaning and purpose of their life, because employment is needed to fulfill their basic needs as well as to overcome the stigma of mental illness. Employment support programs should consider the personal priorities of individuals and provide employment assistance.

Footnotes

Acknowledgments

None to report.

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethics Statement

The protocol of the current study was approved by the institutional review board of the Institute of Health and Sport Sciences of the University of Tsukuba (Taiiku#021-173).

Funding

The study was funded by JSPS Kakenhi (Grant numbers JP21K21104 and JP22K17564).

Informed Consent

All participants completed informed consent to participate in the current study.

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