Work, welfare, and wellbeing: The impacts of welfare conditionality on people with mental health impairments in the UK

The personal, economic, and social costs of mental ill health are increasingly acknowledged by many governments and international organisations. Simultaneously, in high-income nations, the reach of welfare conditionality has extended to encompass many people with mental health impairments as part of on-going welfare reforms. This is particularly the case in the UK where, especially since the introduction of Employment and Support Allowance in 2008, the rights and responsibilities of disabled people have been subject to contestation and redefinition. Following a review of the emergent international evidence on mental health and welfare conditionality, this paper explores two specific issues. First, the impacts of the application of welfare conditional-ity on benefit claimants with mental health impairments. Second, the effectiveness of welfare conditionality in supporting people with experience of mental ill health into paid work. In considering these questions, this paper presents original analysis of data generated in qualitative longitudinal interviews with 207 UK social security benefit recipients with experience of a range of mental health issues. The evidence suggests that welfare conditionality is largely ineffective in moving people with mental health impairments into, or closer to, paid work. Indeed, in many

First, the impacts of the application of welfare conditionality on benefit claimants with mental health impairments.
Second, the effectiveness of welfare conditionality in supporting people with experience of mental ill health into paid work.In considering these questions, this paper presents original analysis of data generated in qualitative longitudinal interviews with 207 UK social security benefit recipients with experience of a range of mental health issues.The evidence suggests that welfare conditionality is largely ineffective in moving people with mental health impairments into, or closer to, paid work.Indeed, in many cases, it triggers negative health outcomes that make future employment less likely.It is concluded that the application of conditionality for people with mental health issues is inappropriate and should cease.

K E Y W O R D S
sanction and support, social security benefits, welfare reform

| INTRODUCTION
Within social security benefit systems, the application of welfare conditionality links eligibility to continued receipt of work-related benefits to claimants' engagement with mandatory, work focused interviews (WFIs), training and support schemes, and/or job search requirements, with failure to undertake such specified activities leading to benefit sanctions (Dwyer, 2016).In recent decades, conditionality has increasingly been applied to working-aged disabled people in receipt of incapacity benefits in many high-income welfare states across the globe (Baumberg Geiger, 2017;Lantz & Marston, 2012;Lindsay & Houston, 2013), and it has become a key component of the UK's "work first" approach to disability benefit reform (Dwyer, 2017;Patrick, 2017).Advocates of welfare conditionality argue that many disabled benefit recipients are essentially unemployed rather than incapacitated.They believe that varying combinations of "carrot" (engagement with compulsory work focused training and support) and "stick" (benefit sanctions for noncompliance) are both justifiable and effective in challenging disabled claimants' attitudinal barriers to paid work and enforcing work norms.Opponents of conditionality within incapacity benefit systems, view it as inappropriate, punitive, and largely ineffective in helping disabled people overcome the significant social and structural barriers they face in relation to obtaining and sustaining paid employment (rf.Patrick, Mead, Gregg, & Seebohm, 2011 for fuller debate).This paper explores two substantive issues.First, the impact that the implementation of welfare conditionality has on people with experience of a range of mental health impairments.Second, its effectiveness in moving such people closer to, or into, paid employment.Part one briefly reviews international literature on welfare conditionality, incapacity benefits, and mental health.The key policy developments that have extended and consolidated welfare conditionality within the UK's incapacity benefit system are also outlined.In part two, the methods used to generate the new empirical data that directly informs the subsequent discussions are summarised.Part three considers the effects of the application of welfare conditionality on the lives of UK-based, working-age benefit claimants with experience of mental health impairments.An analysis of the effectiveness of conditionality within the UK's incapacity benefit system in triggering movements into or towards paid work, for those with mental health issues, is then offered.
The quarter of the world's population affected by mental ill health and impairment continue to face persistent socioeconomic disadvantage, a situation which equally has been strongly associated with poor mental health (Pybus, 2018).In an era in which social inequality and mental ill health are increasing, the experiences of those with mental health impairments are being discredited, and their collective rights to social security diminished compared with others (Pybus, Pickett, Prady, Lloyd, & Wilkinson, 2019).Furthermore, disabled people are increasingly being charged with a responsibility to overcome their personal "failings" and search for, enter, and sustain paid employment or risk forfeiting their claims to what are often meagre out of work social benefits.Conditionality and austerity have combined to shape welfare reform policies, which undermine the substantive ability of social citizenship to deliver even a modicum of social security (Edmiston, 2016).Quantitative analysis "suggests that the procedures of welfare conditionality may be biased against those who are already at risk of social exclusion" (Reeves & Loopstra, 2017, p. 336), including disabled people, because they are unable, rather than unwilling, to comply with the requirements now routinely attached to the receipt of social security benefits.Against this backdrop, this paper makes an original and significant contribution to knowledge by presenting new empirically grounded analysis of the inappropriateness and ineffectiveness of the application of welfare conditionality from the perspective of people with mental health impairments in receipt of social security benefits.

| WORK, WELFARE CONDITIONALITY, AND MENTAL HEALTH
It is broadly acknowledged that, where paid work is the norm, employment generally has positive economic and health impacts for both individuals and wider society.Conversely, the negative impacts of unemployment have also been widely highlighted.For example, a comprehensive review concludes that, "overall, the beneficial effects of work outweigh the risks of work, and are greater than the harmful effects of long-term unemployment or prolonged sickness absence.Work is generally good for health and well-being" (Waddell & Burton, 2006, p. ix).
Low employment rates among people with mental health issues and the high costs to individuals, employers, and the wider economy that this can trigger are also significant concerns for policymakers (Division of Workplace Programmes [DWP]/Department of Health, 2017;OECD, 2015), and a review of international evidence highlights many nations "now formally require disabled people to participate in steps towards work" (Baumberg Geiger, 2017, p. 122).
At any one time, around one fifth of the working-age population may be experiencing mental health issues and that there is a growing prevalence of poor mental health among those in receipt of out of work benefits (OECD, 2015).In a tacit endorsement of welfare conditionality, the Organisation for Economic Cooperation and Development (OECD) dismisses the "standard approach" of exempting jobseekers with mental health impairments from job seeking requirements and highlights the value and efficacy of simultaneous treatment and labour market participation to help ensure "sustainable employment".Acknowledging the need to properly assess mental health as a barrier to employment and placing a requirement on employment services to then provide appropriate personalised support, the OECD report, nonetheless, states, "the expectation and participation required of jobseekers with mental health conditions should be made clear to them in order to encourage, or even in some circumstances, compel them to take up any special services being provided" (OECD, 2015, p. 15-16).Interestingly, the report then makes a distinction between unemployment benefit regimes focused on active "return to work management" and sickness benefit systems, which are seen as "passive" benefit systems primarily concerned with eligibility criteria.Given the extent to which active labour market polices, underpinned by varying measures of welfare conditionality, are increasingly a feature of the incapacity benefit systems in many high-income nations, the OECD's rather simplistic dichotomy is somewhat flawed.Most people with mental health issues want to work, and the provision of appropriate tailored, mental health and employment support packages can help overcome disabling barriers.In such circumstances (re) engagement with paid work may play a role in improving peoples' mental health and their wider social inclusion (Seebohm, 2011).
Whilst few would argue that supporting individuals into meaningful and sustainable work can produce positive outcomes for disabled people, to date, evidence about the consequences of applying welfare conditionality to people experiencing mental health issues remains limited.Davis (2019) explored the impact of benefit conditionality on the mental health of single mothers with low educational attainment reliant on social assistance benefits provided under the Temporary Assistance for Needy Families (TANF) programme in the USA.Comparing different states' varying applications of TANF, he concluded that states with the most intensive conditionality regimes led to worsening mental health outcomes for lone mothers and that "TANF conditionality policies may be further cementing inequalities between advantaged and less advantaged groups through their negative impact on the mental health of low educated single mothers" (2019, p. 265).Two recent UK studies have also considered the effects of welfare conditionality on lone parents' health.Katikireddi, Molaodi, Gibson, Dundas, and Craig (2018) suggest that attaching sanctions-backed work search requirements to benefit receipt has adverse impacts on the mental health of lone mothers with school age children.Additionally, a Cochrane review of the effects of welfare-to-work policies on lone parents' mental and physicalhealth found such interventions to be "unlikely to have any tangible effects", conceding that in some circumstances, "small negative health impacts" were likely to ensue (Gibson et al., 2017).More positively, Sage's (2013) international literature review drew favourable conclusions on the potential of active labour market polices to improve the health of sick and disabled people by reducing negative outcomes such as depression, low self-esteem and motivation, psychological distress, and suicide rates among unemployed people.However, others have argued that the UK's highly conditional benefit regime can undermine the mental health of those subject to it and that it is incompatible with therapeutic principles, and the recovery focused practice of mental health nursing professionals (BABCP, 2016;Conlon, Bush, Ariyaratnam, Brennan, & Owtram, 2015;Jones, 2018).Other UK studies have also raised the concerns of statutory and nonstatutory employment support service providers about how conditionality is being implemented and its potential to cause further harm to service users with mental health issues (Barnes et al., 2017;Dorsett, 2008) and vulnerable groups more generally (Reeves & Loopstra, 2017).
Highlighting distinct national variations, Baumberg Geiger (2017) sets out an international typology of how welfare conditionality is implemented within incapacity benefit systems, which combines two dimensions.First, the "level" (or strength) of conditionality to which a claimant is subject, broadly based on the type and prevalence of benefit sanctions applied to disabled claimants.Second, the extent to which "rehabilitation", defined in relation to the investment in, and quality of, both fitness to work assessments and any employment support that is made available to help disabled people back into employment.On this basis, the UK's incapacity benefit system is described as an exemplar of a "compliance-based system" characterised by high conditionality and weak rehabilitation measures.Baumberg Geiger's judgement is evidenced by developments in UK incapacity benefit policy over the last decade.
The introduction of Employment Support Allowance (ESA) has been described as rendering UK incapacity benefits recipients subject to "workfare" for the first time (Bambra & Smith, 2010).Similarly, the replacement of training programmes focused specifically on assisting people with disabilities and health conditions back into work (e.g., Pathways to Work) with the more generic work programme (WP; 2011-2017) was seen as a "decisive shift towards further compulsion and Work First activation" (Lindsay & Dutton, 2013, p. 187) within employment support for disabled people.Concerns about the quality and effectiveness of the available compulsory support in enhancing the well-being of those mandated onto the WP have also been raised.(Carter & Whitworth, 2017).A documentary review argued that the WP was "suffused in a rhetoric that constructs health-related unemployment as relatively easy to address" (Ceolta-Smith, Salway, & Tod, 2015, p. 262), with only a small number of WP providers specifically referencing the role of health care professionals within their delivery model.

| Conditionality within the UK's incapacity benefit system
Linking continued receipt of incapacity benefits to particular compulsory work search and training requirements under threat of benefit sanction for noncompliance is a relatively recent phenomenon within UK social security.Successive New Labour governments (1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010) were keen to question many assumptions about disabled people's rights and responsibilities in respect of paid work and access to incapacity benefits.An initial policy phase, which emphasised incentivising and supporting incapacity benefit recipients into work through voluntary engagement with the New Deal for Disabled People, soon morphed into policy more overtly focused on enforcing compulsory job search and employment-focused training under threat of benefit sanction.Informed by the Freud Report (2007) and Gregg Review (2008), which favoured extending and intensifying conditionality as a panacea for tackling labour market inactivity and "welfare dependency", ESA was introduced in 2008.ESA replaced Incapacity Benefit, disability related Income Support and Severe Disablement Allowance.Significantly, ESA introduced overt work-related conditionality for working-age incapacity benefit claimants' for the first time (Dwyer, 2016).
Consequently, disabled people in the UK seeking to access social security benefits due to long-term physical, sensory, and/or mental impairment must undergo a work capability assessment (WCA).Undertaken by a private contractor, this assesses a person's functional capacity.Importantly, the WCA outcome also determines the level of conditionality required to retain benefit eligibility.Three potential outcomes may ensue for disabled ESA or Universal Credit claimants.First, those found "fit for work" are subject to full work-related conditionality, that is, maintenance of work availability, alongside up to 35 hr/week of job search/preparation activities, including mandatory work focused interviews (WFIs).Second, those assessed as having "limited capability for work" but deemed likely to be capable of future paid employment are placed in the work-related activity group (WRAG) and required to take mandatory steps to prepare for paid work as instructed.Under both of these outcomes, failure to undertake the personalised work-related requirements as specified in the Claimant Commitment 1 routinely result in the application of benefit sanctions.Third, individuals assessed as having a "limited capability for work and work related activity", because of the severity of their impairments, are placed in the support group and exempted from all work search/preparation requirements and the possibility of benefit sanctions.(Kennedy, Keen, & Mackley, 2017).
Developments under the Conservative/Liberal Coalition and Conservative governments further entrenched welfare conditionality as an integral part of UK social security policy for disabled benefit claimants (Dwyer, 2017;Patrick, 2012).Notable changes included the launch of an enhanced benefit sanctions regime (DWP, 2013) and the introduction of the Work Programme, now replaced by the smaller Work and Health Programme.Within these programmes, the (mainly private) providers of mandatory training packages are allowed a large degree of discretion in the mix of sanction and support they may use to variously encourage/compel disabled claimants, outside the support group, to enter or prepare for paid work.
Three further significant policy developments are noteworthy.First, the UK Government's drive to simplify the benefit system and smooth the transitions between work and welfare through the phased introduction of universal credit (UC; 2013-ongoing).UC merges four means tested benefits and two tax credits (i.e., Jobseeker's Allowance (JSA) and ESA, 2 income support, housing benefit, child tax credit, and working tax credit) and replaces them with a single-variable monthly benefit payment that is adjusted according to a recipient's previous monthly earnings from paid work.Second, the abolition of the additional "limited capability for work" payment (worth an additional £29.05 per week), previously paid to disabled ESA/UC claimants placed in the WRAG.Denounced by the chancellor as a "perverse incentive" that undermined entry into paid work, critics have argued that the loss of this additional payment will increase hardship among disabled people and may, paradoxically, push many further away from employment (Child Poverty Action Group, 2016).Finally, certain powers and budgets for the provision of employment-related support/training have recently been devolved to the Scottish government and municipal authorities in England and Wales.In future, in Scotland, engagement with employment support services provided under the Work and Health Programme is to be entirely voluntary and free from the threat of benefit sanctions (Scottish Government, 2018).In England, employment support will be available on a voluntary basis for a number of specified "vulnerable groups", including disabled people; however, sanctions-backed conditionality will be retained for individuals who have been out of work for over 2 years (Powell, 2018).

| METHODS
This paper offers new analysis of data generated in interviews conducted with the 207 3 people who identified as having a mental health issue/impairment within the qualitative longitudinal (QL) study that was a core component of the Welfare Conditionality: Sanctions Support and Behaviour Change (hereafter WelCond) project, which broadly aimed to explore the effectiveness and ethicality of behavioural conditionality within the UK welfare state.This QL study used purposive nonrandom sampling techniques (Mason, 2002) to recruit respondents through a diverse range of organisations.These organisations were primarily, but not exclusively, third-sector agencies, local authorities, and housing/accommodation providers.By using multiple organisations to support recruitment, but also by conducting fieldwork across 10 locations in England and Scotland, we attempted to avoid the sample bias that can sometimes occur when relying on a smaller network of contacts.
WelCond explored conditionality across a range of policy areas.Consequently, the QL sample consisted of nine different groups of welfare service users subject to varying types and degrees of welfare conditionality.These were recipients of working-age social security benefits (jobseekers, lone parents, disabled people, and Universal Credit claimants), homeless people, social tenants, individuals/families subject to antisocial behaviour orders/family intervention projects, offenders, and migrants, with respondents sampled according to a range of appropriate criteria pertinent to each specified group.For example, 58 respondents were purposively sampled as "disabled people" to take part in the study.
However, across the wider WelCond QL sample as a whole, a total of 207 people (the majority of whom were originally recruited into other specified groups), discussed experiences of mental ill health in their interviews.They identified a wide spectrum of mental health impairments including anxiety, depression, post-traumatic stress disorder, obsessive compulsive disorder, psychosis, and schizophrenia.Many were on medication, some were undergoing, or had previous experience of, various therapies and counselling.A number were grappling with additional problems including homelessness, drug, and alcohol dependency.Dependant on the outcome of their last WCA, these respondents were routinely reliant on one of three main UK working-aged social security benefits, that is, ESA, JSA (if deemed "fit for work"), or UC.Respondents were interviewed up to three times (Waves a, b, and c) at, on average, 12-monthly intervals between July 2014 and July 2017.The interviews were in depth, with question guides focused on eliciting an understanding of people's varied encounters of welfare conditionality within the social security/welfare system, including experiences of WCAs, managing the conditions of their benefit claims, benefit sanctions, and mandatory support, alongside broader discussions around health and well-being within the context of their claim (rf.WelCond, 2018 for fuller methods discussions).
Two core principles, informed consent, and anonymity underpinned the research.Before each interview, information sheets and consent forms were used to revisit discussions about participation and consent.Respondents were given the opportunity to ask questions and informed of their right to withdraw from the study at any time.Interpreters and translated materials were available as required.Interviews were conducted in a variety of locations including cafés, community/support agency offices, and peoples' homes.Respondents received a £20 voucher on completion of each interview.Discussions were audio recorded and verbatim English transcripts produced with each subsequently assigned an anonymised code number (e.g., LO-PD-002b 4 ).A dual approach informed data analysis.To enable temporal analysis across the entire sample, a common "top-down" coding schema was developed, and data were summarised using a framework matrix approach (Lewis, 2007) and QSR NVivo software.Additionally, "bottom-up" thematic analysis (Mason, 2002) of particular subsets of identified transcripts was undertaken.

| THE IMPACTS OF WELFARE CONDITIONALITY ON CLAIMANTS WITH MENTAL HEALTH ISSUES
Discussions now consider two interrelated questions.First, how do UK claimants with mental health issues experience the process of claiming and maintaining social security benefits?Second, how does the conditionality inherent within the UK's benefit system impact on their mental health?Regardless of whether or not an impaired person is claiming ESA, JSA, or UC, the UK system currently combines assessment of eligibility to receive benefit on grounds of incapacity with an attendant judgement about a person's ability to prepare for, and move into, paid work.The outcome of these combined decisions determines the level of conditionality attached to an individual's claim.
Consequently, the three interlinked elements of incapacity assessment, benefit sanctions, and non-negotiable engagement with employment support are vital elements for claiming, and the continued receipt, of working-age incapacity benefits.
For many respondents with mental health impairments, all three elements of the UK's conditional social security system were routinely described as profoundly problematic.The WCA was regularly experienced as an uncaring and insensitive process that appeared to lead to inappropriate decisions about a person's fitness to prepare for, or undertake, paid work.When mental health was under scrutiny, those who attended a WCA appointment regularly reported that the veracity of their personal accounts and the extent and impacts of their impairments were frequently perceived to be disregarded by assessors.
It's all very much based on the physical stuff and they don't take into account the emotional and mental stuff.(BR-AS-009a) If you happen to be having a particularly good day on your medicine, they don't really see the effects the depression can have on you or the bipolar.They just think they're seeing a normal, well-adjusted, healthy person.(GL-AS-024a) The data cited above is illustrative of a wider inadequacy of the WCA process for taking into account the episodic character of many mental health conditions.Many respondents spoke of increased anxiety, fear, and mental distress being triggered by attending impending assessments or the process of mounting appeals.The thought of being put back into that situation where I was going to the Jobcentre and the prospect of sanctions and such like, I actually had a panic attack … In that situation where I was signing on having all those sort of threats hanging over me for a matter of weeks, it had such an impact on me.(ED-SJ-003c) These findings are consistent with a range of wider evidence highlighting serious concerns about the WCA process.
It has been heavily criticised for propagating an individual deficit model of disability that deflects attention away from the barriers to work that disabled people face (HoC/WPC, 2014; Patrick, 2012;Shakespeare, Watson, & Alghaib, 2017), focusing more on physical mobility issues, with inadequate consideration of mental ill health (Maclean, Marks, & Cowan, 2017;Scullion, Dwyer, Jones, Martin, & Hynes, 2019).In 2013, a judicial review found that the WCA substantially disadvantages people with mental health impairments (MIND, 2013).The stress and anxiety that many claimants experience when undergoing the assessment and appeals process (rf.Garthwaite, 2014) has also led to some people abandoning their claims altogether (Citizens Advice Scotland, 2017).The WCA has been further condemned for having serious detrimental impacts on the mental health of those undergoing assessment.A study of claimants from 149 English local authorities, who underwent WCAs between 2004 and 2013, found that the process was associated with an additional 590 suicides, 279,000 additional cases of self-reported mental health problems, and the prescribing of an additional 725,000 antidepressants (Barr et al., 2016b, p. 341).
Advocates of welfare conditionality within incapacity benefit systems often assert that eligibility assessment processes should be responsive enough to determine first whether or not someone with mental health impairments should be subject to welfare conditionality at all, and second, how any conditionality that may be subsequently applied might be personally moderated for disabled claimants, including people with mental health conditions.The first assertion is highly problematic.In 2016, 50% of initial WCA assessment decisions, where disabled people were found "fit for work" or for "work-related activity", were overturned on appeal (Shakespeare et al., 2017).One noted effect of the application of the WCA's stringent criteria has been to move "people with mental health problems onto unemployment benefits, where they receive insufficient support and are subject to a punitive sanctioning policy which has severe consequences for their health" (Barr et al., 2016a, p. 457).
All claimants, regardless of their mental health status, routinely face a range of profoundly negative outcomes, including increased poverty and debt, reliance on charitable and informal support networks, and potential destitution when a benefit sanction is applied (Adler, 2018;Dwyer, 2018a;Fletcher & Wright, 2018).For example, this man with depression described how after being reassessed as "fit for work" a subsequent benefit sanction led to homelessness and, over time, disengagement from the social security system. 5Those with histories of poor mental health who are found "fit for work" or with "work related activity" face an additional burden in that the ever-present threat of a sanction as well as their actual application regularly triggers and exacerbates existing anxieties and illness.The preceding data clearly illustrate the serious mental distress that benefit sanctions engendered for among respondents such as feelings of worthlessness, suicidal thoughts, episodic trauma, and the need for increased medication.
Whilst acknowledgement of the harm that benefit sanctions trigger is vital, it is also necessary to consider the negative effects of the other key component of highly conditional benefit systems, that is, mandatory engagement with specified work search and training activities, under threat of sanction.Stinson (2019) notes that Jobcentre Plus work coaches have discretionary powers to take account of an individual's circumstances and capabilities to apply "easements," which reduce the extent to which someone is required to search for work/engage in WFIs and so forth.However, evidence indicates that easements are not being routinely discussed or appropriately implemented in many cases, including situations where mental illness is an issue.
Sometimes this may be due to unsympathetic work coaches or their lack of understanding of the relevant easements.However, it is perhaps more likely driven by the "work first" approach that underpins the UK's benefit system.This prioritises moving people off welfare and into any work, often leaving little time and space for work coaches to tailor more supportive approaches in tune with individuals' health needs and circumstances (Dwyer, 2018b).Many respondents believed their mental health issues were inappropriately ignored by work coaches.For example, [Work Coach] tells you that you're all right, everything's hunky dory in your life.There's nothing wrong with you, you can work, you can get a job.They can't see inside your head.(GL-AS-016b) Even when work coaches were empathetic to respondents' mental health impairments, work focused outcomes appeared to be prioritised above supporting people's health and wellbeing.For example, BR-JM-002, described a "really nice adviser" who was aware of her ongoing depression and addiction issues and who spoke of "extra support" prior to placing her on the WP.However, when a clash between mandatory attendance at the WP and an appointment at an addiction clinic occurred, the respondent was, nonetheless, sanctioned for nonattendance at the WP despite informing the DWP of a need to attend the clinical appointment.More widely, much of the "support" on offer through Jobcentre Plus or WP providers was experienced as primarily focused on ensuring compliance with the mandatory, work related requirements necessary to maintain eligibility to benefit.Proper consideration of a person's state of mental health was often absent or disregarded, with many respondents feeling pressured to perform mandatory work-related requirements, sometimes with dire consequences.
[At wave a] Being bullied by the job coach to stick on UC … It's just overwhelming me, even more with my depression and anxiety, it's making matters worse … [At wave b] If I'm not fit to work then why am I talking to a job coach?…[At wave c] The stress of UC, the stress of trying to get jobs, and just trying to function within a flat, I ran off to the woods at one point.(BA-JM-014 a-c) When first interviewed, this respondent had recently been made redundant after 15 years in full-time employment, was working part time, subject to "in work" conditionality, and felt under pressure from his work coach to search for more hours to retain eligibility to UC.Unable to manage on his combined wage and in work UC supplements, he was very unwell.He spoke of a plan to abandon his accommodation to escape the depression and anxiety that had been triggered by his impoverished state and the pressure from his work coach.A year later, he confirmed he had subsequently suffered "a breakdown," was on medication, and no longer working due to due to chronic anxiety, recurrent panic attacks, and a new debilitating physical condition.Although at this juncture, the DWP accepted that he was seriously ill and unfit for work, or for work-related activities, he was confused about why a work coach continued to contact him about readiness to work.At our final Wave c interview, some 2 years after our first discussion, the man's health had deteriorated further.Assisted by a healthcare worker, he had successfully applied for supported accommodation.He reported that over the preceding 12 months, he was no longer required to actively seek work and that the "UC people" had become "more human."Nonetheless, he continued to receive texts from UC about filling in his online work search journal, despite being mentally and physically unable to work.The endemic preoccupation with paid work within the UK's highly conditional benefit system appeared to be undermining the parallel treatment offered by healthcare professionals attempting to meet respondents' mental health needs.
Whatever the medical profession are doing, the Jobcentre put all that anxiety back onto you, all the stress back onto you, which the doctors are trying to sort out in the first place, and it's just like it's a vicious circle.(BA-JM-014c) My doctor signed me straight back off again because it was causing so much stress.I couldn't deal with it … [Jobcentre Plus] didn't know anything about your health … It was all about, this is what you have to fulfil.(WSU-IN-AS-005a) Significantly, the extension of welfare conditionality to vulnerable people has a further negative impact on the capacity of welfare professionals to support their clients.Many statutory and third sector organisations are increasingly deflected from their primary roles due to a pressing need to "concentrate on mitigating the impacts of the highly conditional statutory social security system" (Jones, 2019, pp. 111-112).Unprompted, National Health Service staff attending various WelCond events spoke of their ability to deliver effective treatment for people with pressing mental health needs being undermined due to the time they have to dedicate to supporting patients dealing with, and appealing against, flawed WCAs and/or benefit sanctions.

| WELFARE CONDITIONALITY: ENABLING EMPLOYMENT AMONG THOSE WITH MENTAL HEALTH ISSUES?
It has been suggested that many incapacity benefit recipients' are, in effect, unemployed rather than incapacitated (Mead, 2011) and that following the application of a functional capability test to separate out the most severely impaired, demanding work search/preparation activity for the majority of incapacity benefit claimants is justifiable on the grounds that it will enable more disabled people into paid work (DWP, 2008).Analysis of the employment trajectories of the respondents with mental health conditions who participated in the WelCond study does not support these assertions.
Out of the 207 participants who identified as having a mental health impairment at Wave a, 161 subsequently took part in either one or two further repeat interviews over a period of up to 2 years.This enabled us to undertake analysis of any movements into paid work that occurred across the timeline of the repeat interviews.Figure 1 offers a numerical qualitative mapping of any changes in employment status for the 161 respondents who took part in more than one interview.
As can be seen, stasis was by far the most common outcome, with 136 out of the 161 respondents experiencing a lack of change in their employment status over time.In part, this high incidence of stasis can be attributed to the fact that 46 of these 136 respondents remained in the support group of ESA across the timeframe of the repeat interviews.The inertia of these 46 respondents could perhaps be seen as indicative of an appropriately functioning benefit system in which those allocated to the support group, because of the severity of their impairments, were not required to actively seek, or prepare for, paid work as a condition of continued benefit receipt.However, stasis for the remaining 90 respondents (i.e., discounting the 46 who were always in the support group) equated to being out of work at Wave a and remaining unemployed at each subsequent interview.Significantly, only seven people reported being in paid work at their Wave a interview and retaining employment at subsequent Wave b and c interviews; of these, just two retained full-time employment across all three interviews, whilst a third remained selfemployed.Movements, towards paid work, where people who were not in paid work at the start of the study then managed to find some form of employment and/or increase their hours moving forward, occurred for only a small minority.Similarly, movements away from the paid labour market (where people who were initially working at Wave a and/or b, then became unemployed, or whose terms of employment deteriorated significantly across the period of the study) and undulating movements (where people who were not in paid work at Wave a, reported being in some form of work at Wave b and then unemployed or underemployed again at Wave c) were also much rarer.
It needs re-emphasising that WelCond was a qualitative longitudinal study that utilised a purposive sampling strategy to recruit people who were subject to welfare conditionality in various settings.The numbers set out are therefore in no way statistically representative of the wider population of people with mental health impairments in receipt of UK out of work social security benefits.However, Figure 1  It's had no effect.There's no difference.Because I've been on these work placements, and done this and done that, everything they've asked me to do, and I still haven't found a job.(SH-JM-002b) You're just basically there as a number, sign a bit of paper and put on your way.I don't feel as though there's any help for you.They don't hinder me; they don't help me; they do nothing.(GL-AS-017b) Although a minority of respondents reported more positive interactions with Jobcentre Plus and Work Programme staff, the majority the application of welfare conditionality was not only inappropriate but also counterproductive.The assumption that I'm trying to get something for nothing, the guilt that was laid on me when I was trying to find work and seriously mentally ill with depression and anxiety, the information from people at the Jobcentre that I should just pull myself together … Yes, stress and distress.… .I think if the system had been more humane I wouldn't now be quite so far away from the world of work.
(GL-AS-022a-c) I was planning last year to be going back to work, and then it's the way I was dealt with by the benefits really knocked me back … depression again.It caused me a lot of stress, a lot of anxiety, the way I was being treated.(ED-BW-001a) Oakley's (2016) analysis of statistics from the Labour Force Survey found that those with a mental health condition are 30% less likely to move into work than disabled people with other impairments.The wider ineffectiveness of welfare conditionality in closing the disability employment gap and moving those with long-term physical and mental impairments into work is well documented.Against a performance target of 16%, in its first 2 years of operation, the WP only managed to place 5% of disabled WRAG clients into paid work (Hale, 2014).
Evaluations of the WP (Newton et al., 2013) and the earlier Pathways to Work scheme (Weston, 2012) have also found that the compulsion, conditionality, and sanctions inherent with within ESA inhibit the likelihood of disabled claimants developing supportive relationships with their work coaches and do very little to move people closer to employment.Such findings are particularly pertinent for the 248,000 people with mental and behavioural issues allocated to the WRAG of ESA (Lord Low, Meacher, & Grey-Thompson, 2015), given that its "regime of conditionality" had adverse impacts on claimants' mental health and "left participants in the WRAG fearful, demoralised and further away from achieving their work related goals or participating in society than when they started" (Hale, 2014, p. 5).

| CONCLUSIONS
Since the introduction of ESA in 2008 and the subsequent extension and intensification of sanctions backed compulsion in the UK incapacity benefit system, a substantial body of evidence has noted the ineffectiveness of welfare conditionality in moving disabled people closer to or into paid employment (e.g., Barr et al., 2016a, b;Dwyer, 2017;Hale, 2014;HoC/WPC, 2014, 2015;Lindsay & Houston, 2013;Newton et al., 2013;Weston, 2012).This paper adds significantly to this debate by more specifically evidencing the particular ineffectiveness and unsuitability of utilising welfare conditionality within benefit systems for people with mental health impairments.The analysis presented highlights that the processes and pressures, which are fundamental to the functioning of highly conditional "work first" benefit regimes appear to have recurrent and profoundly negative impacts on the well-being of people with histories of mental illness.These include triggering or exacerbating mental illness whilst simultaneously pushing many further away from the possibility of paid work.Across our substantial qualitative sample, applying welfare conditionality to people with mental health impairments in receipt of social security benefits routinely did little to facilitate their transitions into the paid labour market.
Although paid work can have many beneficial impacts, including for some individuals with mental health impairments, the mandatory enforcement of ineffective work search and work-related norms often engender little more than punitive "psychological tyranny" (Stewart, 2018).When requirements "to demonstrate certain attitudes or attributes in order to receive benefits or other support" (Freidli & Stearn, 2015, p. 40) dominate, and unemployment becomes seen as a condition caused by an individual's "bad attitude", any pretence of care and support within social security systems are likely to quickly morph into coercion and control with considerations linked to the positive mental health and well-being of claimants easily disregarded.

ENDNOTES
1 UC recipients must agree and sign the Claimant Commitment at the outset of their claim.This specifies any work related responsibilities required for benefit receipt and the sanctions that apply for noncompliance.Work-related requirements in the Claimant Commitment should be tailored to an individual's needs, capabilities, and circumstances to make them realistic and achievable (DWP, 2016). 2 ESA will not disappear entirely under UC.Disabled people with the required previous National Insurance contributions placed in the WRAG will continue to claim "new style ESA" for a year (DWP, 2018).
3 The 43% incidence of mental ill health (i.e., the 207 out of 481 respondents recruited) within our sample is significantly higher than the one in four annually recorded rate for adults in UK society.This difference is explained by two factors.First, the majority of our purposively sampled respondents were living in poverty, which in itself, "increases the risk of mental health problems and can be both a causal factor and a consequence of mental ill health (Elliott, 2016, p.7)." Second, the WelCond project recruited and interviewed a large number of respondents from vulnerable groups previously identified by the Chief Medical Officer for England as having higher risk of experiencing mental ill health, for example, homeless people, offenders, people with multiple/complex needs, and asylum seekers and refugees (Davies, 2014).Many of these groups also face additional disadvantages when looking for work, which may go some way to explaining the high levels of stasis that we found.

I
really did want to commit suicide, because I know I'm not fit for work.I can't work in crowded places … [On subsequent successful appeal] Overjoyed, basically, because you know deep down you're not fit for work, but they're saying you are…The distress levels it causes.The worrying you do about it.(GL-AS-036a)

[
At wave a] Living on the street … They decided I wasn't sick so took me off Income Support, put me on Jobseekers.Then that all went wrong … I couldn't pay the rent because I was sanctioned… my rent ended up backing up, my head was all over the place I just couldn't deal with it … [At wave b] I don't claim benefits at the moment.I just don't want to know.Too much of a headache, proper stress … I don't sign on anymore … The only thing it has done is make it more difficult basically … I get my breakfast at [homeless charity] … Evenings, there's different places dotted about where you can get something to eat.(SH-JM-007a-b) It felt like there might even be more sanctions in the pipeline.I just went into meltdown for several weeks actually where I couldn't function … All I could think of was the enormity of the struggle, to get out of this nightmare, get the sanction overturned, appeal the sanction, deal with the fresh threat of sanctions (LO-SJ-017a) [At wave b] Very vulnerable … I feel on tenterhooks really about what will happen, which makes me sad because I do want to work and I am applying for jobs … I just feel like if I put a foot out of place the money will be withdrawn.When that sanction happened, I literally did feel really quite suicidal, lowest point … [At wave c] I felt trapped really and just it doesn't matter what I do, if it's not going to be enough there's no point carrying on.(BR-JM-002b/c) does offer a stark visual representation of the limited extent to which movements into work occurred for the majority of respondents with mental health impairments who took part in the study.Analysis of the qualitative data generated in the repeat interviews further highlights the ineffectiveness of welfare conditionality in enabling respondents with mental health conditions into work.At best, rather than facilitating transitions into employment, "signing on" at the Jobcentre and mandatory engagement with various training and work preparation/search requirements made little or no difference to people's motivation to look for work or chances of obtaining paid employment.
Routinely, being subject to WCAs, mandatory work search and training requirements under threat of sanction in order to retain eligibility for benefit further undermined respondents' mental health and pushed people further away from the possibility of future work.[At wave A] It didn't add anything to my skill set … no, I don't think the course has helped … [At wave B] The actual face-to-face (WCA) interviews have been punishing, cruel, humiliating, unhelpful … they have set me back in terms of my mental health and my physical health every single one … [At wave C]

F
I G R E 1 Change in employment status across the 161 respondents with mental health issues who took part in repeat interviews [Colour figure can be viewed at wileyonlinelibrary.com]