Overview
- There is a clear link between being out of work and poor mental health.
- Modern medicine routinely fails to consider social factors when treating patients.
- Taking someone off work has considerable consequences.
- Addressing social factors must become a high priority–soon!
In 2012, NBC News reported a haunting wave of suicides among Italian workers devastated by the economic downturn.1 The notes they left behind were not complex. “I can’t live without work.” “I am a failure.” “My business is like my family — if it fails, I fail with it.”
These are not the words of people who simply lost a paycheck. They are the words of people who lost themselves.
As a spine surgeon for 33 years, I often removed myself from conversations about mental health. At that time, I had no idea that chronic mental pain and physical pain are the same entity that arises from dysfunction at the cellular level. I felt that all pain was structural, and if I could not identify an anatomical source, there was nothing I could do. Work was either possible or it wasn’t. When it wasn’t, I took patients off the job, and I felt I was helping them. It was also easier than navigating the details of light duty, modified hours, or the messy intersection of a person’s life and their diagnosis. What I failed to understand for far too long is that removing someone from work is never a neutral act. It can be — and often is — its own form of harm.
Being labeled
What is ironic and now disturbing to me is that people with any type of disability are often labeled as difficult, “less than,” and not wanting to return to work. They may be quickly dismissed from care and often don’t feel heard. I was taught that the way to solve the disability crisis was to be tougher and push people back to work. And I did. It hit me hard about seven years into my practice that a major reason patients on disability were often difficult was that they were so angry from being trapped by pain and the system. As their hopes were repeatedly dashed by yet another medical visit, despair would set in. It is the reason that I call this scenario “The Abyss.” It is a very dark hole without an apparent way out.
Unfortunately, over my 45 years in medicine, I have only observed this scenario getting worse, much worse. Doctors spend less time, order more ineffective interventions, and quickly place people on disability. However, deep down, no one wants to be viewed as disabled and dependent on others. People want to be heard and seen, and being labeled as anything other than a fellow human is devastating. The story of the Italian workers committing suicide is just one facet of the situation.
The Neuroscience of Belonging
The human nervous system is not designed for isolation and purposelessness. It is designed for connection, contribution, and safety. When we feel safe — genuinely safe, not just medically stable — the body shifts into a state where healing becomes possible. Threat physiology does the opposite: it keeps the system on high alert, flooding us with stress hormones, amplifying pain signals, and contracting the very capacities we need to recover.
Work, at its best, is one of the most powerful safety signals available to us. It provides structure, social connection, a sense of competence, and economic stability — all of which the nervous system reads as evidence that the world is not dangerous. Strip those signals away, and the brain doesn’t simply note an absence. It interprets the void as a threat.
This is why social isolation causes multiple different chronic mental and physical symptoms that are not identifiable on traditional imaging. The same danger circuits fire. The same distress pathways are activated.2The label on the experience — “loneliness” versus “back pain” — is less important to the nervous system than the underlying signal: something is wrong, and I am not safe.
What Research Now Confirms
A landmark Australian study published in BMC Public Health examined 369 participants enrolled in the country’s Disability Employment Services (DES) program, nearly half of whom had a psychosocial disability — depression, anxiety, PTSD, psychosis — as their primary condition.3 The findings were unambiguous. Those who were working had significantly higher mental health and well-being scores than those who were not. The gap was not small. Among people with psychosocial disability, the mental health score for employed participants was 47.5 compared to 36.9 for those without work — a difference that is clinically meaningful, not merely statistical.
But the study did something more important than confirm what we already suspected. It asked a harder question: what kind of relationship do people have with their healing when the employment support system either helps or fails them? Through in-depth interviews conducted over time, researchers identified five distinct narratives — five different ways a person can experience the intersection of mental health, work, and the support they receive.
Some people recovered in spite of the system, finding work through their own determination while the formal support services around them created obstacles. Others recovered with the system when they were fortunate enough to encounter a claims person who listened, adapted, and treated them as a whole person rather than a placement target. Still others were recovering along a fluctuating path, tethered to hope by thin threads of connection and the belief that work would eventually be possible. And then there were those for whom the system actively undermined recovery, where poor matches, withheld information, and dismissive relationships compounded the already significant weight of mental illness. The most common story of all was simply survival: exhausted people caught in systems that weren’t built for them, trying not to go under.
The evidence has confirmed what those Italian workers already knew in their bones.
The Quality of Work and Support Matters
Not all work heals. Work that is mismatched to a person’s skills and values, work that is precarious or casual, work that involves bullying or powerlessness, worsens mental health outcomes.4 The Australian study found that people working more or fewer hours than they wanted, or on casual rather than permanent contracts, had significantly lower wellbeing scores than those in stable, aligned employment.
What consistently distinguished helpful from harmful experiences was not the program, the funding model, or the bureaucratic structure. It was the individual relationship. Claims examiners who took the time to understand a person’s history, listen to their aspirations, acknowledge their fears, and respond with flexibility and respect facilitated recovery. Those who slotted people into inappropriate jobs, withheld available resources, or communicated through power and compliance pressure did not.
Doctors’ Blind Spot
When I think about the patients, I took off work without fully reckoning with the consequences, I recognize now that I was treating a fragment of a person rather than the whole. Modern medicine is extraordinarily effective for acute interventions and strikingly underprepared for the social and environmental forces that account for most chronic illness. Poverty, isolation, housing instability, workplace toxicity, and ongoing trauma are not background conditions. They are the primary drivers of whether a nervous system stays in chronic threat or moves toward safety and healing.
Social determinants of health account for about 80% of a person’s chronic illnesses and diseases.5 So, doctors can only contribute a small portion to an individual’s well-being. Factors include poverty, lack of opportunity, oppressive work environments, ongoing physical, emotional, or sexual abuse, societal instability, homelessness, bullying, social media, overexposure to social media, inadequate police protection, and authoritarianism.6 If a person’s annual income is less than $40,000 in the US, the incidence of a diagnosable anxiety disorder reaches 100%.7
Helping someone heal while ignoring their environment is not just incomplete. It is often counterproductive. The body cannot be treated as a closed system when it is responding, moment to moment, to an open one.
Work is medicine. But like any medicine, it can heal or harm depending on dose, quality, and whether the person receiving it feels like a patient being processed or a human being who feels heard and supported. Doctors are not being trained to acknowledge or address these social issues either collectively or individually. The medical system has essentially washed its hands of this responsibility. Our medical, vocational, and social systems need to reckon with how to address people as humans and in the context of their circumstances. Not someday. Now.
References
- Lavanga, Claudio. “In debt or jobless, many Italians choose suicide.” NBC News World Blog, May 9th, 2012.
- Eisenberger N, et al. “Does rejection hurt? An fMRI study of social exclusion.” Science (2003); 290
- Devine A, et al. ‘I’m proud of how far I’ve come. I’m just ready to work’: mental health recovery narratives within the context of Australia’s Disability Employment Services. BMC Public Health (2020); 20:325. https://doi.org/10.1186/s12889-020-8452-z
- Lane RD, et al. Biased competition favoring physical over emotional Pain: A possible explanation for the link between early adversity and chronic pain. Psychosomatic Medicine (2018); 80:880-890. DOI: 10.1097/PSY.0000000000000640
- World Health Organization; Commission on Social Determinants of Health. Closing the gap in a generation. 2008 summary report. WHO REFERENCE NUMBER: WHO/IER/CSDH/08.1
- Simran L, Hoverman A, Allison S, and Kiffer Card. What is Needed to Promote the Uptake and Implementation of Social Prescribing? Canadian Alliance of Social Connection and Health – Research Report, 2024.
- Rose, Mark. Anxiety Disorders. NetCE (2022); Sacramento, CA.
David Hanscom, MD, is a retired orthopedic spine surgeon and the founder of the Dynamic Healing framework. He is the author of Calm Your Body, Heal Your Mind, and maintains resources at backincontrol.com.