Mental Health Stigma for Providers: A Hidden Challenge Among Us

, ,

Stigma poses a serious risk to quality of care and accessibility.

The stigma that continues among health care providers in psychiatry, psychology, and other mental health professions both is ironic and poses a serious risk to quality care, accessibility, and societal efforts to reduce mental health stigma. Stigma is defined as a “social process, experienced or anticipated, characterized by exclusion, rejection, blame or devaluation that results from experience or reasonable anticipation of an adverse social judgment about a person or group.”1,2 There is a glaring misconception that mental health stigma is less pronounced within psychiatric settings, but research has continuously debunked this claim.

Adams and colleagues emphasize that greater exposure to mental health problems has no bearing on stigmatization or help-seeking behaviors in medical professionals.3 In fact, depression rates among resident physicians (28.8%) are higher than the rates found in the general population.4 Further, 1 in 10 physicians will develop a substance use disorder at some point in their lifetime.5 In a study of 648 clinical psychologists, two-thirds of participants reported their own mental health struggles and indicated that shame and worries about the negative consequences for their careers were barriers for disclosing and seeking professional help.6 Furthermore, the emergence of the COVID-19 pandemic has strongly contributed to poor mental health among health care workers.7 Despite many organizations encouraging health care providers to access psychological services geared toward dealing with the impact of the pandemic, stigma around mental health support continues to fuel the reluctance to utilize available resources.8

This overwhelming evidence suggests that stigma prevents mental health providers from seeking their own care and points to the urgent need to develop programs and strategies targeting harmful attitudes in psychiatric settings. For the purposes of this article, we will use the term mental health workers to refer to any professional who provides care to individuals with mental health problems, including but not limited to psychiatrists, other physicians, psychologists, nurses, and social workers. The aim of our article is to: (1) elucidate the barriers that prevent mental health workers from seeking care for themselves; (2) showcase personal vignettes and quotes from mental health workers confronted by these barriers; and (3) provide concrete recommendations for diminishing stigma and other barriers in mental health settings. Figure 1 shows direct quotes provided by mental health workers regarding mental health stigma.

Barriers Between Mental Health Providers and Treatment

First, stigma in the workplace is arguably the most significant contributing factor to mental health workers’ hesitancy to openly speak about their psychological struggles.9 This stigma includes the perceptions of mental health by mental health workers. In a review of stigma and negative beliefs about mental health within the nursing profession, a number of themes emerged including devaluation of mental health in the workplace, lack of resources to support the provision of safe and competent psychiatric care, as well as pessimistic attitudes toward client prognosis and outcomes.10 The review concluded that while nurses are receivers of mental health stigma, they also perpetuate stigma through negative attitudes of fear, blame, and hostility toward psychiatric patients. The potency of stigma among physicians has also been demonstrated. A review of 17 studies across 11 countries suggested that physicians demonstrate negative attitudes toward individuals with serious mental illness, especially perceptions of dangerousness and desire for social distance.11 These findings are another reminder that greater familiarity with mental health populations does not safeguard against stigma in health care settings.

Second, mental health workers tend to hold themselves and their colleagues to unrealistic standards when it comes to self-care. Self-care is defined as engagement in actions that support one’s own physical and emotional wellness.12 Thompson and colleagues found that most physicians expect themselves and their colleagues to work when they are unwell, despite not holding patients to the same standard.13 Despite nurses’ knowledge of the benefits of self-care, research shows that many nurses are unable to engage in self-care activities due to barriers such as lack of time and money, lack of institutional support, poor social support, and unhealthy work schedules.14 Barnett cites a number of alarming studies indicating that up to 60% of psychologists admit to working despite knowing their distress adversely affects the quality of services they deliver to clients.15

Furthermore, studies have found that psychologists who notice signs of distress in a colleague are more likely to ignore the situation than to offer assistance.16 The consequences of neglecting self-care can be dire for mental health workers, and it further raises a question of ethics. Indeed, the American Psychological Association considers self-care as an “ethical and moral imperative” required to provide sound and responsible caring to clients.17 Inadequate self-care leads to burnout, which has been linked to suboptimal client care practices, double the rate of medical errors, and negative attitudes toward mental health problems.18,19 Mental health workers’ negative beliefs and attitudes toward mental health discourages admission of their own personal struggles and prevents them from seeking appropriate assistance.

Third, there are barriers at the organizational level that make mental health workers feel unsupported by their leaders and workplaces. Organizational barriers, in particular, can be perceived as “unchangeable” and eventually trigger feelings of powerlessness, which in turn can instill a sense of inadequacy, failure, and disillusionment.20 In many health care settings, long work hours, high work intensity, overnight duties, and minimal support from other colleagues is normalized, thereby leaving mental health workers to cope in isolation and resign from efforts to address their mental health problems.20,21 This loss of autonomy and lack of meaning at work, as well as suffering in silence for the sake of not “looking weak,” prevents mental health workers from sharing their experiences with their colleagues and fuels imposter syndrome.21,22

Imposter syndrome is defined as a pattern of behavior where individuals experience strong self-doubt in their capabilities, as well as persistent fear of being outed as a “fraud.” Imposter syndrome has been associated with higher rates of psychological distress and work-related burnout.23,24 Further, the infrastructure of many organizations is not conducive to abolishing mental health stigma. For instance, organizations lack emphasis on the importance of mental health in their mission statements or organizational communications, lack the infrastructure to support healthy behaviors (eg, healthy food options, fitness facilities, “quiet”/meditation rooms to promote breaks), and fail to invest in benefit packages sufficient to cover the high cost of mental health services. These limitations serve as deterrents to acknowledging that a problem exists and exacerbate concerns around confidentiality.

Case Vignette 1

In the middle of her psychology residency, “Lisa” was faced with a contentious divorce, which resulted in anxiety, depression, and posttraumatic stress disorder symptoms. She had never experienced mental health problems to this degree, and for the first time in her life, she required medication to function. Her performance in the program was negatively impacted. For example, her concentration difficulties significantly impaired her ability to write reports by agreed upon deadlines.

Although she tried to manage her work independently, Lisa realized very quickly that she had to speak to her supervisors about her mental health problems and the accommodations she would require. She was immediately stricken by fear, worry, and shame. She was afraid her supervisors would perceive her as a “liability” or as “different” from her fellow residents. She worried that her autonomy would be compromised, resulting in no choice but to temporarily withdraw from the program. She mustered up the courage to speak to her supervisors, who met her with understanding, support, and solution-focused accommodations to help her function at work. Contrary to her beliefs, her supervisors commended her for her courage to speak up and never made her feel as if she were “less than” her colleagues at work. Her autonomy was respected, the appropriate supports were implemented, and she graduated from her residency program.

Case Vignette 2

“Jerry” is a 30-year-old, early-career physician who is just finishing his fellowship in geriatric psychiatry in California. He is very excited about his first potential position, which is based at a large community hospital in the Midwest, not far from where his parents live and where his fiancée has found work as a software designer. In his mid-20s, Jerry became very depressed after his relationship with his first fiancée ended. He was hospitalized on 2 occasions for suicidal depression and alcohol use disorder. He has a license to practice medicine in California and had no worries about submitting his application to the state medical licensing board in his home state.

However, when the state medical board received his application, Jerry received a call that there were significant concerns about his fitness to practice medicine, given his past depression, suicidal behaviors, and alcoholism, and the fact that he continued to take the antidepressant sertraline and the alcohol anticraving medication naltrexone. It was made clear to him that if the board moved forward with his licensing, it would be with monitoring by a psychiatrist appointed by the board who had the power to recommend termination of his medical license, should his mental health deteriorate. Jerry consulted an attorney to challenge this decision by the state medical board. Ultimately, he made the difficult decision to stay in California.

Discussion

In the first vignette, Lisa is met by her supervisors with compassion, support, and the appropriate accommodations to help her succeed at work. Her fears about being perceived as a “liability” were debunked by her supervisors, and on a larger scale, this helped reduce the stigma we see in health care settings. Unfortunately, in the second vignette, the circumstances do not end favorably for Jerry. The vignette highlights that mental health stigma roots back to—and still infiltrates—training and licensing organizations. Indeed, in states where licensure applications ask the most questions about mental illness, physicians are 20% more likely to refrain from seeking mental health treatment.25

Recommendations

Figure 2 depicts our recommendations for reducing mental health stigma in the workplace. Given that research shows that organizational factors play a larger role in burnout, organizations should pave the way in embedding mental health training into school and work curriculums (pillar 1), normalizing mental health experiences (pillar 2), and providing appropriate resources to their mental health workers (pillar 3).26

Reducing mental health stigma begins with taking a proactive approach by educating students in undergraduate and graduate programs. The prevalence rate of mental health problems among mental health workers should be shared early on in training programs. Further, education on the importance of self-care should be implemented, as there is a lack of emphasis on this topic in medical and graduate training programs.27,28

Moreover, mental health experiences need to be normalized within health care settings. Leaders can trail blaze by (1) obtaining psychoeducation and training of their own; (2) imparting their knowledge; (3) normalizing the use of therapists and helplines for mental health; (4) modifying working conditions in accordance to changing employee needs; (5) sparking productive conversations around email responsiveness outside of business hours; (6) implementing anonymous mental health surveys to gauge the workplace’s ecosystem; and (7) sharing anonymous results for the purposes of reducing stigma and initiating collaborative problem-solving. Additionally, leaders can cultivate engagement by encouraging open dialogue about common struggles in the workplace and by sharing their own struggles. Research by Fuda and Badham indicates that leaders’ willingness to model their vulnerability is perceived as courageous by their team members and encourages them to follow suit.29

Finally, there needs to be investment in resources for mental health workers, which can be achieved in the following ways: (1) leaders directing mental health workers to free resources that are grounded in evidence-based practices, such as cognitive behavioral therapy and mindfulness, to help workers skillfully navigate mental health in the workplace (eg, apps such as Breathe2Relax, Insight Timer, Tactical Breather from PsyberGuide, Mindfulness Coach); (2) investment in opportunities for social connectedness and inclusion (gatherings, support groups, volunteer opportunities); (3) promotion of self-care and work-life balance (eg, normalizing breaks, providing group discounts for gym memberships, encouraging workers to join the Mindshare community); and (4) open conversations about occupational wellness and burnout. Self-care is most effective when practiced as a proactive measure aimed at reducing stress and thereby avoiding progression to negative outcomes such as burnout.30

Concluding Thoughts

The irony of the pronounced stigma within the mental health profession will continue if systemic solutions are not implemented. Mental health professionals should not be expected to suffer in silence or to treat their own mental health problems, in the same way that dentists are not required to fill their own cavities, lawyers are not expected to represent themselves, and surgeons do not conduct their own surgeries.

Stigma exists in mental health settings and prevents help-seeking behaviors. Barriers exist at the individual, training, and organizational levels. The change that organizations, stakeholders, and leaders will see in their workplace ecosystems will be commensurate to the efforts and resources they invest into abolishing mental health stigma. As long as mental health stigma persists, resources offered through organizations will continue to be underutilized. It is time to practice what we preach! Our voices should serve as pillars of strength not only for our clients, but also for our colleagues.

Ms Sharif-Razi is a PhD candidate who delivers clinical services to individuals with mental health problems in Toronto, Canada. Ms Zanjani is an architectural designer specializing in mental health support in Los Angeles, California. Dr George is a professor of psychiatry in the Temerty Faculty of Medicine at the University of Toronto, and clinician-scientist at the Centre for Addiction and Mental Health in Toronto, Canada. He is also a member of the editorial board of Psychiatric Times™ and incoming coprincipal editor of Neuropsychopharmacology, the official journal of the American College of Neuropsychopharmacology.

References

1. Goffman E. Stigma: Notes on the Management of Spoiled Identity. Prentice Hall; c1963:1-41.

2. Lowe DJE, Simpkin E, George TP. Dual diagnosis: double the stigma, double the trouble. Psychiatric Times. 2022;39(5):26-27.

3. Adams EF, Lee AJ, Pritchard CW, White RJ. What stops us from healing the healers: a survey of help-seeking behaviour, stigmatisation and depression within the medical profession. Int J Soc Psychiatry. 2010;56(4):359-370.

4. Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. JAMA. 2015;314(22):2373-2383.

5. McLellan AT, Skipper GS, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ. 2008;337:a2038.

6. Tay S, Alcock K, Scior K. Mental health problems among clinical psychologists: stigma and its impact on disclosure and help-seeking. J Clin Psychol. 2018;74(9):1545-1555.

7. Spoorthy MS, Pratapa SK, Mahant S. Mental health problems faced by healthcare workers due to the COVID-19 pandemic-a review. Asian J Psychiatr. 2020;51:102119.

8. Weston MJ, Nordberg A. Stigma: a barrier in supporting nurse well-being during the pandemic. Nurse Lead. 2021;20(2):174-178.

9. Abbey S, Charbonneau M, Tranulis C, et al. Stigma and discrimination. Can J Psychiatry. 2011;56(10):1-9.

10. Ross CA, Goldner EM. Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: a review of the literature. J Psychiatr Ment Health Nurs. 2009;16(6):558-567.

11. Stone EM, Chen LN, Daumit GL, et al. General medical clinicians' attitudes toward people with serious mental illness: a scoping review. J Behav Health Serv Res. 2019;46(4):656-679.

12. Myers SB, Sweeney AC, Popick V, et al. Self-care practices and perceived stress levels among psychology graduate students. Train Educ Prof Psychol. 2012;6(1):55-66.

13. Thompson WT, Cupples ME, Sibbett CH, et al. Challenge of culture, conscience and contract to general practitioners’ care of their own health: a qualitative study. BMJ. 2001;323(7315):728-731.

14. Ross A, Bevans M, Brooks AT, et al. Nurses and health-promoting behaviors: knowledge may not translate into self-care. AORN J. 2017;105(3):267-275.

15. Barnett JE, Baker EK, Elman NS, Schoener GR. In pursuit of wellness: the self-care imperative. Prof Psychol Res Pr. 2007;38(6):603-612.

16. Good GE, Thoreson RW, Shaughnessy P. Substance use, confrontation of impaired colleagues, and psychological functioning among counseling psychologists: a national survey. Couns Psychol. 1995;23:703-721.

17. Ethical Principles of Psychologists and Code of Conduct. American Psychological Association. Accessed September 19, 2022. http://www.apa.org/ethics/code/index.aspx

18. Morse G, Salyers MP, Rollins AL, et al. Burnout in mental health services: a review of the problem and its remediation. Adm Policy Ment Health. 2012;39(5):341-352.

19. Søvold LE, Naslund JA, Kousoulis AA, et al. Prioritizing the mental health and well-being of healthcare workers: an urgent global public health priority. Front Public Health. 2021;9:679397.

20. De Hert S. Burnout in healthcare workers: prevalence, impact and preventative strategies. Local Reg Anesth. 2020;13:171-183.

21. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018;283(6):516-529.

22. Bravata DM, Watts SA, Keefer AL, et al. Prevalence, predictors, and treatment of impostor syndrome: a systematic review. J Gen Intern Med. 2020;35(4):1252-1275.

23. Mullangi S, Jagsi R. Imposter syndrome: treat the cause, not the symptom. JAMA. 2019;322(5):403-404.

24. Villwock JA, Sobin LB, Koester LA, Harris TM. Impostor syndrome and burnout among American medical students: a pilot study. Int J Med Educ. 2016;7:364-369.

25. Dyrbye LN, West CP, Sinsky CA, et al. Medical licensure questions and physician reluctance to seek care for mental health conditions. Mayo Clin Proc. 2017;92(10):1486-1493.

26. Moss J. Burnout is about your workplace, not your people. Harvard Business Review. December 11, 2019. Accessed September 19, 2022. https://hbr.org/2019/12/burnout-is-about-your-workplace-not-your-people

27. Wallace JE. Mental health and stigma in the medical profession. Health (London). 2012;16(1):3-18.

28. Posluns K, Gall TL. Dear mental health practitioners, take care of yourselves: a literature review on self-care. Int J Adv Couns. 2020;42(1):1-20.

29. Fuda P, Badham R. Fire, snowball, mask, movie: how leaders spark and sustain change. Harv Bus Rev. 2011;89(11):145-148.

30. Rupert PA, Dorociak KE. Self-care, stress, and well-being among practicing psychologists. Prof Psychol Res Pr. 2019;50(5):343-350.