Associative Stigma among Mental Health Professionals

Abstract

In contrast with growing attention given to the stigma experiences of mental health service users, the stigma literature has paid almost no attention to mental health professionals. This study focuses on experiences of associative stigma among these professionals. We investigate the link between associative stigma and three dimensions of burnout as well as job satisfaction among mental health professionals, and the link of associative stigma with self-stigma and client satisfaction among service users. Survey data from 543 professionals and 707 service users from diverse mental health services are analyzed using multilevel techniques. The results reveal that among mental health professionals associative stigma is related to more depersonalization, more emotional exhaustion, and less job satisfaction. In addition, in units in which professionals report more associative stigma, service users experience more self-stigma and less client satisfaction. The results reveal that associative stigma is related to more depersonalization, more emotional exhaustion, and less job satisfaction among mental health professionals.

Keywords

associative stigma burnout job satisfaction mental health services multilevel research self-stigma service user satisfaction

One-quarter to one-third of the general population experiences a mental health problem at least once (World Health Organization International Consortium in Psychiatric Epidemiology 2000), yet mental illness remains one of the most stigmatized human conditions. Empirical studies based on theoretical frameworks such as the labeling perspective (Scheff 1966), modified labeling perspective (Link 1987; Link et al. 1989), and theory of self-stigma (Corrigan and Watson 2002) have revealed detrimental consequences for job opportunities (Link 1982; Glozier 1998), housing opportunities (Page 1977), life satisfaction (Markowitz 1998), self-esteem, self-efficacy (Link et al. 2001; Wright, Gronfein, and Owens 2000), and obtaining professional care (Vogel, Wade, and Hackler 2007). The literature on the stigma of mental illness typically focuses on the general public (Angermeyer et al. 2005; Phelan et al. 2000) or mental health service users (Link et al. 1997; Rosenfield 1997) and has paid almost no attention to mental health professionals. To address this deficit, this study focuses on experiences of associative stigma among these professionals. We define associative stigma as stigma that mental health professionals experience because they are associated with persons who belong to a stigmatized category in society, namely, people with mental health problems. We investigate the association of associative stigma with three dimensions of burnout and job satisfaction among professionals and the link of associative stigma with self-stigma and client satisfaction among service users.

Background

Stigma and Mental Health Professionals

Mental health professionals are generally thought to experience stigma in two primary ways (Schulze 2007). First, professionals are often—implicitly or explicitly—regarded as perpetrators of stigma. Several recent empirical studies document the stigmatizing attitudes of mental health professionals (Hugo 2001; Jorm et al. 1999; Nordt, Rossler, and Lauber 2006) and reveal how mental health professionals’ treatment of service users contributes to stigmatization for service users (Chaplin 2000; Sartorius 2002). Second, mental health professionals may be considered victims of stigma when the general public has negative attitudes about them (Von Sydow and Reimer 1998). For example, McGuire and Borowy (1979) found that mental health professionals have lower professional prestige than do other health professionals.

This article draws heavily on Halter’s (2008) concept of “associative stigma.” Associative stigma, or courtesy stigma (Goffman 1963), can be defined as stigma that persons experience not because of their own (attributed) characteristics but because they are associated with persons who belong to a stigmatized category in society. This concept has mainly been applied to family members of stigmatized persons (Angermeyer, Schulze, and Dietrich 2003; Phelan 2005; Phelan, Bromet, and Link 1998).

However, the concept can also be applied to mental health professionals, who may be the target of negative attitudes or treatment because they are associated with the target group they serve. As Halter (2002:24) describes, “the public . . . may tend to associate the nurses with the pathologies they treat, resulting in the stigmatization of the specialty itself.” Mental health specialties such as psychiatric nursing appear to have a very low status when compared with other nursing specialties. A recent study found that nurses, in general, perceive psychiatric nurses as unskilled, illogical, idle, and disrespected (Halter 2008). Schulze (2007:145) reports that mental health professionals are portrayed in the media as “neurotic, unable to maintain professional boundaries, drug or alcohol addicted, rigid, controlling, ineffectual, mentally ill themselves, comically inept, uncaring, self-absorbed, having ulterior motives, easily tricked and manipulative, foolish and idiotic.”

Both the original labeling perspective (Scheff 1966) and the modified labeling perspective (Link et al. 1989) acknowledge that mental health services are crucial locations for the labeling and elicitation of stigma associated with mental health. However, the precise mechanisms that operate within mental health services and the role that professionals and their interactions with service users play in contributing to stigma remain unclear. Clarifying the specific mechanisms of the stigma process can enhance our understanding of how mental health stigma operates.

From Goffman’s (1963) work, we know that courtesy stigma is acquired through connections with stigmatized people. However, much of our knowledge about courtesy, or associative, stigma processes in general is derived from studies on family members of persons with mental health problems. This perspective provides a limited understanding of associative stigma that is particular to family relationships and does not necessarily translate to other kinds of relationships. The dynamics between mental health professionals and their service users, which is a professional relationship, may be very different from those among family members. Whereas professionals are connected with service users only through a social relationship, family members also have a biological relationship (Phelan 2005). Moreover, the professional nature of the social relationships between mental health professionals and users may manifest in several ways (Kitson 2003; Scanlon 2006). Professional relationships are work related and limited in time and place and are also less personal because a team of professionals is typically responsible for several service users, and often for one aspect of care, in accordance with the specific profession. In addition, the contractual and explicit therapeutic nature of the care relationship is in contrast to lay caring, which is based on motives such as love, altruism, duty, and necessity. For these reasons, we pay particularly close attention to the work context and the specific dynamics between mental health professionals and mental health service in this study. However, we expect some degree of similarity across contexts, such as the consequences of stress for mental health or the processes of emotional contagion in relationships (see below). Therefore, a better understanding of the consequences of associative stigma processes for mental health professionals might also enhance our understanding of the social complexities of mental health care more broadly.

This study focuses on two research questions concerning the effects of associative stigma. First, in line with research on the adverse effects of stigma for service users (Link et al. 2001; Markowitz 1998) and the negative consequences of associative stigma perceived by family members (Östman and Kjellin 2002), we investigate the effects of associative stigma on the work-related well-being of mental health professionals. Second, as the social interaction between service providers and service users constitutes a key process in mental health care, this study will also investigate the relationship between associative stigma among professionals’ and service users’ well-being.

Associative Stigma among Mental Health Professionals and Their Work-Related Well-Being

In our examination of the effects of associative stigma on mental health professionals, we focus specifically on the effects on work-related well-being, given that associative stigma among mental health professionals is acquired through association with their target groups in their workplaces. We treat associative stigma as a job stressor, analogously to other studies that consider stigma a general stressor (Rüsch et al. 2009). We build on the social stress perspective (Pearlin 1981, 1989) as well as perspectives that specifically emphasize the relationship between working conditions and mental health (Karasek 1979) and utilize burnout and job satisfaction as indicators of work-related well-being.

Burnout is a key indicator of work-related well-being, especially among persons performing “people-work” or “emotion-work.” Work-related well-being is conceived of as a response to chronic emotional and interpersonal stressors on the job (Maslach, Schaufeli, and Leiter 2001). We treat associative stigma as one of these chronic emotional and interpersonal stressors that might produce burnout and will investigate the relationship of associative stigma with each of three dimensions of burnout—cynicism or depersonalization, emotional exhaustion, and perceived inefficacy (Maslach et al. 2001). Job satisfaction is a more general indicator of work-related quality of life. We expect that the distress related to associative stigma will eventually decrease job satisfaction. Both indicators of work-related well-being are interrelated, and their causal order is not always clear-cut (Dolan 1987), but in line with other research (Maslach et al. 2001; Wolpin, Burke, and Greenglass 1991), we consider job satisfaction as the final outcome indicator.

Other determinants of work-related well-being should not be ignored, however. Autonomy and support, which are assumed to impede burnout and stimulate job satisfaction, represent two job characteristics that are particularly important in human service organizations in general and in (mental) health care specifically (Ben-Zur and Michael 2007; Karasek 1979; Maslach et al. 2001; Ross, Altmaier, and Russell 1989). Furthermore, we include an indicator of the mental health status of professionals to control for their affective status as a source of common method variance (Podsakoff, McKenzie, and Lee 2003). This leads to our first two main hypotheses: (1) A larger number of associative stigma experiences will be associated with more burnout for mental health professionals and (2) a larger number of associative stigma experiences will be associated with less job satisfaction for mental health professionals due to burnout (see Figure 1). Our examination of both relationships will control for the level of job autonomy and control, support from colleagues, and professionals’ mental health status.

Figure 1.

Conceptual Model

Associative Stigma among Mental Health Professionals and the Well-Being of Mental Health Service Users

Our second goal is to investigate whether associative stigma among professionals is associated with the well-being of service users. We anticipate an association, given the crucial role that interpersonal contact plays in the provision of mental health care. The job stress literature has demonstrated the link between job stress and performance. Professionals’ working conditions in mental health services can affect their interactions with service users (Holland et al. 1981; Weisman and Nathanson 1985). Moreover, higher stress among health professionals is associated with worse interpersonal performance with service users (Motowidlo, Packard, and Manning 1986; Stewart and Barling 1996). In a review study, Cohen (1980:95) suggests that stress is related to “a decreased sensitivity to others. This includes a decrease in helping, a decrease in recognition of individual differences and an increase of aggression.” This decreased sensitivity to others reflects one of the dimensions of burnout, as mentioned above. Thus, professionals with more associative stigma experiences could be less involved with the service users, resulting in strained relationships between professionals and service users. These poor relationships may, in turn, enhance the stigma experiences of service users (Goffman 1963). Schulze (2007:138–39) showed that poor contact with mental health professionals and poor quality of mental health services are the second and third most frequent stigma experiences mentioned by service users and their families: “Patients felt stigmatized by a lack of interest in their person . . . patients did not get the personal attention they needed, craving for personal contacts with someone else than their fellow-patients.” Another study revealed that impersonal and standardized care can contribute to self-stigma (Verhaeghe and Bracke 2008).

Stigma experiences of service providers might also enhance feelings of stigma among service users because of processes of emotional contagion that can occur in emotional labor (Pugh 2001). Displayed emotions of service providers can affect the moods of service users and thus have an impact on their attitudes toward the services (Barger and Grandey 2006; Pugh 2001). Emotional reactions are a key element in the stigma process (Link et al. 2004). Therefore, professionals with associative stigma experiences could display their related emotions, which in turn could affect the emotional state of their service users.

This leads to our third and fourth research hypotheses: Experiences of associative stigma will have negative effects on burnout and job satisfaction, which in turn (3) will be positively associated with self-stigma among service users and (4) will be negatively associated with service user satisfaction.

Whereas previous empirical studies on the link between work-related well-being of professionals and satisfaction of service users have already confirmed the link between professionals’ burnout and clients’ satisfaction (Halbesleben and Rathert 2008; Leiter, Harvie, and Frizzell 1998) and the link between professionals’ job satisfaction and clients’ satisfaction (Weisman and Nathanson 1985), this study will focus on the role of stigma experiences of professionals and service users. The third and fourth hypotheses will be analyzed from the point of view of service users, with their self-stigma experiences and satisfaction as dependent variables (see Figure 1). We control for two other dimensions of stigma experiences—social rejection and stigma expectations—that do not directly refer to experiences within the current mental health service organization but could affect self-stigma experiences. Furthermore, we will take into account service users’ mental health status, length and intensity of their current treatment, length of their total treatment history, age, gender, education, income, and marital status.

Data and Methods

Data

We used survey data from a larger research project on stigma established in 2005 in Flanders, the Dutch-speaking region of Belgium. Belgium is characterized by a very late deinstitutionalization of mental health patients and still has one of the largest numbers of psychiatric beds per 100,000 inhabitants in Europe. A two-stage sampling procedure was used: First, organizations were sampled, and second, service users and providers within these organizations were selected. Five types of services were enrolled in the study. Psychiatric hospitals offer only mental health care, whereas psychiatric wards in general hospitals provide specialized mental health care within the context of general hospitals. Whereas both provide predominantly full-time inpatient care, part-time care is increasing. In addition to medical care and psychotherapy, a whole range of vocational or day-structuring activities is offered in these settings. Community mental health centers offer ambulatory mental health care for service users who come once a week or once a month, most often for counseling. Psychiatric rehabilitation centers and day activity centers are settings that day patients typically attend during the week. The composition of the service user population and the type of activities offered (e.g., counseling, vocational activities, recreational activities) varies considerably. In 2005, Flanders counted 38 psychiatric hospitals, 34 psychiatric wards of general hospitals, 76 community mental health services, 9 psychiatric rehabilitation centers, and 47 day activity centers. To obtain diversity with regard to type of institution, we included a sample of 8 organizations from each organization type described above. These organizations were randomly selected; refusals (n = 10) were replaced by other organizations from the same type, except when they were announced too late (n = 3) or when no other organization of that type existed (n = 1). From the 46 organizations that were contacted, the final sample size was 36 (78 percent): 8 psychiatric hospitals, 7 general hospitals, 8 day activity centers, 7 psychiatric rehabilitation centers, and 6 community mental health centers.

Within these organizations, units specifically for youth or the elderly were excluded, as were units specializing in service users with cognitive disorders or mental retardation. Furthermore, among the selected centers and units, service users were excluded if they had cognitive disorders or mental retardation, if they were in a stage of too acute illness to participate (determined by professionals), and if their knowledge of Dutch was insufficient. The service users who met the criteria and who were present on a date that had been agreed on beforehand with the supervisor were invited to participate. Informed consent was obtained after an introduction by the researcher. Of the 1,174 eligible service users, 846 (72 percent) agreed to participate. Within the selected centers and units, all mental health professionals were invited to complete questionnaires; 597 of the 954 invited (63 percent) agreed to participate. Due to ethical considerations and privacy legislation, we were not able to gather information about the service users and professionals who were unwilling to participate in the study. Due to missing values on some key variables, the final working sample for the current analyses includes 707 service users and 543 professionals. Of the 707 service users, 389 receive services at psychiatric hospitals, 102 at psychiatric wards of general hospitals, 66 at community mental health centers, 92 at day activity centers, and 58 at psychiatric rehabilitation centers. Their mean age is 39.59 (SD = 11.76), and 54.9 percent are women. Of the 543 professionals, 349 provide services at psychiatric hospitals, 80 at psychiatric wards of general hospitals, 36 at community mental health centers, 37 at day activity centers, and 41 at psychiatric rehabilitation centers. The working sample consists of 272 psychiatric nurses, 73 general nurses, 64 psychologists, 60 vocational trainers, 47 social workers, 21 pedagogues, 15 physiotherapists, 14 psychiatrists, 14 social nurses, and 96 service providers in a miscellaneous category consisting of a diversity of occupations. The mean age of the sample is 37.6 (SD = 10.45); 75.1 percent are women.

Measures

Mental health professionals

Concerning associative stigma among mental health professionals, no standardized measure exists. We used four items with five answer categories ranging from 1 (never) to 5 (often), to ask professionals (1) whether some people react negatively when they hear the professionals work in mental health care organizations, (2) whether some people make jokes about the professionals’ working there, (3) whether the professionals feel ashamed of working there, and (4) whether they are sometimes reluctant to tell other people where they work (see the appendix). A majority of the professionals answered “never” to the last two questions. Furthermore, the original measure had an alpha reliability coefficient of .51, which is moderate for a four-item scale. Therefore, the instrument was not used as a Likert-type scale but instead as an index. After having dichotomized the items by distinguishing experiences that never happened from those that at least seldom occurred, affirmative answers to the four items were summed. The index, which refers to the number of types of stigma experiences one ever had, has values from 0 (no stigma experiences) to 4 (four types of stigma experiences) (M = 1.73, SD = 0.84).

Burnout was measured by a Flemish translation of the Maslach Burnout Inventory (Vlerick 1995), with 22 items with scores from 0 (never) to 6 (every day). Mean scores on the three conventional subscales were computed. Depersonalization was measured using five items (M = 0.72, SD = 0.66, alpha = .59), emotional exhaustion was measured using nine items (M = 1.30, SD = 0.89, alpha = .83), and the experience of failing in personal accomplishment was measured using eight items (M = 1.09, SD = 0.80, alpha = .79).

Job satisfaction was operationalized by a Likert-type scale composed of five items derived from Pfeffer and Davis-Blake (1990) and Martin and Roman (1996), with scores ranging from 1 (absolutely disagree) to 5 (absolutely agree). The scale refers to general feelings of pleasure and motivation in the current job, using items such as “I do my job with pleasure” (M = 4.03, SD = 0.70, alpha = .83).

Job autonomy and control were measured by an instrument (Haynes et al. 1999) consisting of six items with scores from 1 (not at all) to 5 (very much) (M = 3.20, SD = 0.76, alpha = .82). An example item is, “To what extent do you determine the methods and procedures you use in your work?”

To operationalize relationships with colleagues, a four-item indicator was used (Haynes et al. 1999), with answering scores ranging from 1 (not at all) to 5 (totally) (M = 4.18, SD = 0.71, alpha = .88). An example item is, “To what extent can you count on your colleagues to help you with a difficult task at work?”

To measure mental health status, a 12-item version of the General Health Questionnaire (Goldberg and Hillier 1979) was used. Mean scores range from 1 to 4, with higher scores’ referring to better mental health (M = 3.16, SD = 0.29, alpha = .81).

Finally, two main sociodemographic characteristics were included as control variables: gender (women = 1, men = 2) and age (in years).

Mental health service users

Self-stigma is conceptualized as feelings of shame and inferiority that are directly related to treatment in the current mental health service organization. We used a measure derived from Fife and Wright (2000) consisting of 5 items with scores from 1 (completely false) to 5 (completely true) (M = 2.76, SD = 1.29, alpha = .92). An example item is, “Since I have come to this center, I have come to feel inferior.” Social rejection refers to negative interactions with people outside of the center due to having received help at the center. It was measured by a scale derived from Fife and Wright, using 5 items with scores from 1 (completely false) to 5 (completely true) (M = 3.11, SD = 1.22, alpha = .91). An example item is, “Since I have come to this center, some people treat me with less respect.” Stigma expectations refer to beliefs about what the general population thinks about persons with mental health problems, and it was measured by the Devaluation Discrimination scale developed by Link et al. (1989). We translated this scale and slightly adapted it by replacing references to “mental hospital” and “ex-…” with “persons who receive(d) psychological help,” as suggested by Link et al. (2002). This instrument consists of 12 items with answer categories from 1 (completely disagree) to 4 (completely agree) (M = 2.69, SD = 0.42, alpha = .83).

Client satisfaction was measured using a Dutch translation (De Brey 1983) of the Client Satisfaction Questionnaire (Nguyen, Attkisson, and Stegner 1983). It consists of 8 items such as “How would you rate the quality of the services you received?” with scores from 1 to 4 (M = 3.07, SD = 0.53, alpha = .89). Psychiatric symptoms were operationalized by the 18-item version of the Brief Symptom Inventory (Derogatis 2001), using a Dutch translation of its parent instrument, the SCL-90 (Arrindell and Ettema 1986). The items are scored from 0 (not at all) to 4 (always) (M = 1.43, SD = 0.94, alpha = .94).

Professionals provided information about the psychiatric diagnosis of service users. Three main diagnostic categories were used as dichotomous variables (1 = present, 0 = absent)—mood-related disorders (29.1 percent), psychotic-related disorders (19.3 percent), and substance-related disorders (26.8 percent). Service users for whom information was missing—nearly 9 percent of the sample—were included as a separate category. Length of current treatment was measured in months (M = 10.69, SD = 8.68), whereas number of years since first treatment (M = 17.20, SD = 31.8) was computed as the difference between current age and the age at which the service user received mental health care for the first time in his or her life. Intensity of current treatment was measured as the number of hours a week the service user spends in the current mental health center (M = 79.81, SD = 68.39).

Finally, the following background variables were taken into account: gender (women = 1, men = 2), age (in years), and marital status (married or cohabiting = 1, 24.7 % single, divorced, or widowed = 0). Education was measured by means of four categories (primary education = 1, college or university degree = 4; M = 2.92, SD = 0.77). Income was measured by a proxy variable indicating how easily one can get by with one’s income (1 = very difficult, 6 = very easy; M = 3.31, SD = 1.45).

Analyses

To respect the clustered data-sampling procedure, multilevel analyses were performed using the program HLM 6 (Raudenbush, Bryk, and Cheong 2004), which accounts for the nonindependence of the observations. To address our first research problem concerning the professionals, the following model was specified for each of the four dependent variables:

Y_{i j} = γ_{00} + \sum_{p} γ_{1 p} X_{p i j} + u_{0 j} + r_{i j},

(1)

with γ₀₀ as the intercept, γ₁ _p as p indexed first-level regression coefficients (i.e., fixed effects corresponding to gender, age, mental health status, autonomy, etc.), r_ij as the individual-level error, and u ₀ _j as the organization-level error. The errors are assumed to follow normal distributions with means 0 and variances σ² and τ₀₀, respectively.

Concerning the second research problem, data on two levels were needed. We could not link the data for each service user with characteristics of his or her service provider in a direct way, as no one-to-one relationship between service users and service providers exists. Since a team of professionals share responsibility for a service user, data were aggregated to the team level by taking the average value for each variable for the team. Therefore, a multilevel analysis with two levels was performed for service users, with characteristics of the service users at the lowest level and aggregate scores of mental health professionals at the highest level. The models were specified as follows:

Y_{i j} = γ_{00} + \sum_{p} γ_{1 p} X_{p i j} + \sum_{q} γ_{0 q} Z_{q_{j}} + u_{0 j} + r_{i j},

(2)

with γ₀₀ as the intercept, γ₁ _p as p first-level fixed effects corresponding to service user covariates, γ₀ _q as q second-level fixed effects corresponding to service provider covariates, r_i _j~N(0, σ²) as the individual level error, and u ₀ _j ~N(0, τ₀₀) as the level-2 error.

The models specified in equations 1 and 2 were estimated using the restricted maximum likelihood method as the sample size for each unit was relatively small. For all variables at the interval or ratio level, grand mean centering was applied. No sampling weights were used. Within scales, item correlation substitution was used to deal with missing values: A missing value was replaced by the value on the item within the scale that has the highest correlation with the item (Huisman 1999). Cases with missing data information on other variables were omitted from the analyses (listwise deletion). Finally, standardized multilevel regression coefficients are reported in the next section. They are based on the fixed effects reported by HLM 6, with robust standard errors. These coefficients are computed by multiplying the unstandardized coefficients with the standard deviation of the respective variable and dividing by the standard deviation of the dependent variable.

Results

Associative Stigma Experiences among Mental Health Professionals

Generally speaking, experiences of associative stigma can be considered rather low (see the appendix). The mean score is 1.74, which means that service providers experience, on average, nearly two of the four types of associative stigma. Very few professionals mentioned feeling ashamed of working in the current mental health center or hesitant to tell other people about it. In contrast, a larger number of professionals acknowledged experiencing negative reactions to their jobs, and even more of them reported that people make jokes about their work.

We found no differences in associative stigma between women (M = 1.76, SD = 0.79) and men (M = 1.67, SD = 0.98) or according to age (p = .621). However, professionals with better mental health reported significantly less stigma (p = .016). Furthermore, we found differences between professional groups: Nurses reported the most stigma experiences (M = 1.90), followed by physiotherapists (M = 1.65), social workers (M = 1.47), and psychologists (M = 1.38). Furthermore, differences between the types of organizations appeared: psychiatric hospitals (M = 1.85), psychiatric wards of general hospitals (M = 1.86), community mental health centers (M = 1.64), day activity centers (M = 1.41), and psychiatric rehabilitation centers (M = 0.88).

Associative Stigma among Mental Health Professionals and Their Work-Related Well-Being

Associative stigma is positively associated with depersonalization and emotional exhaustion but not with failure in personal accomplishment (see Table 1). Furthermore, associative stigma is negatively associated with job satisfaction. This effect diminishes slightly when controlling for burnout, revealing that the negative effect of stigma on job satisfaction can be partially attributed to higher levels of emotional exhaustion. For both depersonalization and emotional exhaustion, associative stigma is an even more important determinant than job autonomy. Furthermore, job autonomy is associated with fewer experiences of failure of personal accomplishment. In addition, professionals who feel more work autonomy are more satisfied with their jobs, which can be partially attributed to greater feelings of personal accomplishment. Supportive relationships with colleagues seem important for job satisfaction and for all dimensions of burnout; the exception is depersonalization (p = .052). More positive mental health status is associated with less burnout and more job satisfaction. No consistent relationships were found regarding sociodemographic background variables. Men report more depersonalization compared to women, whereas older professionals report less depersonalization. Men are less satisfied with their jobs, which can be attributed to greater feelings of depersonalization. Furthermore, older professionals are more satisfied with their jobs, which is attributable to lower levels of depersonalization. In sum, findings indicate that associative stigma is associated with more depersonalization and emotional exhaustion and with less job satisfaction, which largely supports our first and second hypotheses.

Table 1.

The Effect of Associative Stigma, Job Characteristics, and Control Variables on Three Dimensions of Burnout and Job Satisfaction among Mental Health Professionals—Results from a Multilevel Analysis (Standardized Multilevel Regression Coefficients)

	Depersonalization	Emotional Exhaustion	Failure of Personal Accomplishment	Job Satisfaction
Gender	.172***	.053	−.017	−.100*	−.077
Age	−.133***	−.059	−.021	.067*	.043
Mental health status	−.161**	−.258***	−.182***	.163***	.082*
Support colleagues	−.086	−.165***	−.167***	.265***	.209***
Autonomy	−.045	−.079	−.181***	.246***	.206***
Associative stigma	.151***	.136**	.027	−.161***	−.126**
Depersonalization					−.088
Emotional exhaustion					−.134**
Failure of personal accomplishment					−.168***
Variance components
τ₀₀	.004	.061	.009	.02	.011
σ²	.391	.499	.691	.343	.319

Note: Deviance statistics not reported since restricted maximum likelihood was used as method of estimation.

p < .05. **p < .01. ***p < .001.

Associative Stigma among Mental Health Professionals and the Well-Being of Mental Health Service Users

Associative stigma is positively associated with self-stigma among service users (see Table 2, Model 1.1). This effect is not explained by any one of the three dimensions of burnout generally or by depersonalized treatment of service users specifically (see Model 1.2), showing that higher levels of self-stigma among service users are not attributable to more impersonal treatment by the professionals. Burnout has no significant effect on self-stigma. Furthermore, enhanced feelings of self-stigma among service users of units where professionals have higher levels of associative stigma cannot be attributed to the job satisfaction of the professionals (see Model 1.3).

Table 2.

The Effect of Associative Stigma and Burnout among Mental Health Professionals on Experiences of Self-Stigma and Client Satisfaction among Mental Health Service Users. Controlled for Service Users’ Sociodemographic Characteristics and Features of Mental Health (Service Use)—Results from Multilevel Analyses (Standardized Multilevel Regression Coefficients)

	Self-Stigma			Client Satisfaction
	Model 1.1	Model 1.2	Model 1.3	Model 2.1	Model 2.2	Model 2.3.A	Model 2.3.B	Model 2.4
Service provider variables
Associative stigma	.134***	.147***	.146***	−.119*	−.120*	−.082	.063	−.043
Depersonalization		−.018	−.019		−.032	−.040	.063	−.041
Faillure of personal accomplishment		.075	.074		−.017	−.001	.078	.101
Emotional exhaustion		−.012	−.012		.097	.087	.065	.117
Job satisfaction			−.001				.080*	.166*
Service user variables
Gender	−.036	−.037	−.037	−.090*	−.090*	−.102**	−.092*	−.104**
Age	.070	.065	.064	.098°	.100*	.113*	.096*	.108*
Education	.021	.024	.024	−.052	−.053	−.049	−.054	−.050
Marital status	.008	.012	.012	.028	.027	.030	.026	.029
Income	.029	.030	.030	.049	.050	.058	.050	.058
Symptoms	.320***	.321***	.321***	−.183***	−.186***	−.103**	−.183***	−.100*
Number of years since first treatment	−.090*	−.085*	−.084*	.031	.033	.013	.038	.018
Length current treatment	.021	.018	.018	−.017	−.013	−.009	−.009	−.005
Intensity current treatment	.110**	.103**	.103**	−.047	−.030	−.004	−.035	−.010
Mood disorder	−.042	−.040	−.040	−.032	−.033	−.044	−.091*	−.014
Psychotic disorder	.047	.042	.041	−.082*	−.084*	−.080	.031	.028
Substance disorder	−.068	−.069	−.069	−.044	−.044	−.058	−.036	−.048
Missing	−.023	−.018	−.019	−.044	−.061	−.069	−.087	−.083
Social rejection	.317***	.319***	.319***	−.097*	−.091*	−.015	−.041	−.055
Stigma expectations	−.012	−.010	−.010	.034	.033	.029	−.072	−.080
Self-stigma						−.252***		−.253***
Variance components
τ₀₀	.041	0.037	.041	.036	.038	.032	.034	.028
σ²	1.104	1.106	1.105	.222	.222	.212	.222	.212

Note: Deviance statistics are omitted; see comment in Table 1.

p < .05. **p < .01. ***p < .001.

We also found that service users receiving care in units where the professionals indicate more associative stigma are less satisfied with the services (see Model 2.1). Like the results for self-stigma, this association cannot be explained by any of the dimensions of burnout, and none of the latter is associated with service user satisfaction (see Model 2.2). However, lower levels of service user satisfaction in units where professionals report more associative stigma can be explained by service users’ self-stigma (see Model 2.3.A). Associative stigma therefore appears to enhance self-stigma among service users, which then leads to lower service user satisfaction. However, another explanation for the link between associative stigma among professionals and service user satisfaction is also supported by the data (see Model 2.3.B). In units with higher levels of associative stigma, professionals are less satisfied with their jobs, as indicated earlier in Table 1. This lower job satisfaction level seems to partially explain why higher associative stigma levels are linked with lower service user satisfaction. In units with higher job satisfaction levels, service users are more satisfied.

Concerning the other service user–level variables, the strongest effect is found for symptoms: The more symptoms are present, the more self-stigma and the less service user satisfaction are reported. The importance of self-stigma is revealed by the fact that nearly half of the effect of symptoms on service user satisfaction is due to self-stigma and that self-stigma is the most important determinant of service user satisfaction. Furthermore, service users experiencing more social rejection report more self-stigma and less service user satisfaction. The latter effect is explained when taking self-stigma into account, however, which again confirms the importance of self-stigma. In addition, service users with prolonged service use over the course of their lives report less self-stigma, whereas users with more intensive current treatment report more self-stigma. Finally, men, younger people, and those with psychotic disorders are generally less satisfied with the services received.

To summarize, hypotheses 3 and 4 were only partially supported by the data. In accordance with the third hypothesis, we found a positive relationship between associative stigma among professionals and self-stigma among service users. However, this link was not explained by burnout. Hypothesis 4 was partially confirmed because we found a negative link between associative stigma and service user satisfaction, which was reduced when taking self-stigma into account. However, an alternative mechanism, via job satisfaction, was also supported by the data.

Discussion and Conclusion

The point of departure for this article is that mental health professionals may experience associative stigma and that this may affect their work experiences and the quality of the service they provide. Two questions were addressed: First, what are the effects of associative stigma on professionals’ work-related well-being? Second, what are the consequences for the well-being of their service users? We found that associative stigma is associated with depersonalization and emotional exhaustion among mental health professionals, and the latter contributes to a decrease in job satisfaction. Associative stigma among professionals can clearly be considered a job stressor, in line with other studies considering stigma a stressor for those stigmatized (Rüsch et al. 2009) and for those associated with the stigmatized such as family members (Baxter 1989; Östman and Kjellin 2002). Although professionals differ from family members in their relationships with service users in several ways, similar processes with regard to the link between stigma and well-being appear. Our finding of these similarities is in accordance with the findings of other scholars who stress that differences between lay caring and professional caring should not be exaggerated (Hem and Heggen 2003; Kitson 2003): considering, for instance, that emotions cannot be eliminated from professional care.

Findings further demonstrate that the detrimental effects of associative stigma among service providers spill over to mental health service users, as associative stigma is also associated with self-stigma and dissatisfaction among service users. Regarding the link between associative stigma and service user satisfaction, two processes emerged from the data. First, associative stigma is related to job dissatisfaction, which is directly linked with service user satisfaction. A similar association between provider satisfaction and user satisfaction has been found in other empirical studies (Weisman and Nathanson 1985). The fact that the relationship between professionals’ associative stigma experiences and service user satisfaction can be explained by job satisfaction is in accordance with the job stress literature, which states that job satisfaction is related to better interpersonal performance (Cohen 1980). The quality of relationships between professionals and service users is crucial to the provision of quality mental health services. Not surprisingly, service users are more satisfied in units with higher levels of job satisfaction among professionals. Emotional contagion effects could be involved, too, when displayed emotions related to satisfaction among professionals affect the mood of service users, resulting in higher levels of reported service user satisfaction (Barger and Grandey 2006; Pugh 2001).

We also found that associative stigma is directly related to self-stigma among service users, which seems to contribute to dissatisfaction with mental health services. This process is also in accordance with arguments that associative stigma worsens interpersonal relations between service providers and users. This finding supports other studies showing how negative interpersonal relationships can lead to (self-)stigma among service users (Schulze 2007; Verhaeghe and Bracke 2007), which in turn enhances feelings of dissatisfaction. Emotional contagion processes, which link stigma experiences of service providers and users, could also be at play, but that seems less plausible as only a few providers report feelings of shame or inferiority.

Several limitations of this study should be noted. First, in the absence of a well-defined standardized measure of associative stigma among service providers, we designed an instrument for this study. This inventory needs to be developed further, taking into account that negative reactions from others are more apparent than negative reactions or emotions from service providers themselves. Second, the cross-sectional design of the study limits our confidence concerning the causal nature of the relationships. Alternative causal pathways cannot be excluded. Service providers with low job satisfaction levels might, for instance, report more associative stigma because they see all work-related issues in a negative way. However, given that the association between associative stigma and job satisfaction remains after controlling for mental health status, this alternative pathway seems less plausible. Furthermore, associative stigma experiences generally involve how others react to the professionals. It might be less plausible that job dissatisfaction—which is not necessarily reported to others—could elicit stigmatizing reactions in the environment of professionals. The reasoning applies even more for service users. An alternative causal pathway would be that high levels of self-stigma in service users would lead to an environment in which professionals react in a more negative way. As we do not assume a direct relationship between the environment of professionals and the service users, this pathway seems less plausible.

Third, the results are limited to Belgium, which is characterized by a late deinstitutionalization of mental health patients. The issue of stigma might be especially relevant in such a context. There is some evidence that stigma might be lower in more deinstitutionalized care (Angermeyer, Link, and Majcherangermeyer 1987; Verhaeghe, Bracke, and Bruynooghe 2007). Furthermore, cross-national differences in levels of stigma have been reported (Pescosolido et al. 2008). Replication of this study in other contexts is needed for greater certainty about its generalizability.

Fourth, due to ethical considerations and privacy legislation, information about people refusing to participate could not be gathered. Also, selection effects cannot be excluded. We believe that most of these potential selection effects might contribute to an underestimation of the levels of stigma and overestimation of well-being as reported by both service providers and users. Hence, we have reason to believe that the detrimental outcomes of the processes revealed in our analyses are underestimated. First, stigma acts as a major barrier, respectively, to seeking professional mental health care (Vogel et al. 2007) and to choosing to work in the mental health professions (Cutler et al. 2009). In addition, both service users and professionals with more severe stigma experiences or lower satisfaction probably drop out of the settings more readily. Furthermore, among those providers and users who were eligible, those with more stigma experiences and those with lower satisfaction levels were probably less inclined to participate in this study.

Fifth, the processes revealed could differ between mental health services, as stigma experiences can be affected by service characteristics (Angermeyer et al. 1987; Verhaeghe and Bracke 2007). Our descriptive analysis revealed differences in associative stigma between types of services and professionals, and other studies have also revealed differences in attitudes toward several professions (Von Sydow and Reimer 1998). However, it would go too far to differentiate between services and professionals in our analyses.

Despite these shortcomings, this study is important because it is the first to pay particular attention to the empirical link between associative stigma experiences among service providers and its consequences for both service providers and service users, using a multilevel research design and analysis techniques on a relatively large data set.

What are the implications of an association between associative stigma and service users’ well-being? Schulze (2007) pointed out that some scholars consider professionals “victims” of stigma because they are stigmatized too, while others see professionals as “offenders” when they stigmatize service users by the way they treat them. Our results suggest that both aspects are present, as mental health professionals who are victims become offenders when the detrimental effects of associative stigma experiences spill over from providers to service users due to specific features of the relationship between professionals and service users in human service organizations. An unexpected finding was that burnout and particularly depersonalized treatment play no role in the relationship between associative stigma among service providers and self-stigma among service users. Future research could help to clarify which characteristics of the relationship between professionals and service users play a key mediating role. It is notable that, in general, we found low levels of associative stigma and almost no feelings of self-stigma or internalized stigma among the service providers. Selection effects could play a role here, leading service providers who are more vulnerable or sensitive to associative stigma to leave their jobs. However, more substantial reasons could be present, too. Future research will need to investigate why professionals do not seem to internalize stigma.

This study has broader theoretical implications for several research domains. First, in the stigma domain, two processes related to stigma experiences among mental health service users have been stressed: (1) direct discrimination and devaluation, which refer to negative behaviors from the general public toward service users (Angermeyer and Matschinger 2005; Scheff 1966), and (2) more subtle social-psychological processes such as expectations of devaluation and discrimination (Link et al. 1989) and internalized stigma (Corrigan and Watson 2002) by service users. Our results point to a third type of stigma process in which professionals play a more active role: Their associative stigma experiences seem to reproduce stigma during service encounters.

Second, these findings have important implications for the work/health experiences of mental health professionals. These professionals are known to be particularly vulnerable to burnout because of the nature of their work, such as the very intense interaction with service users and the confrontation with challenging behaviors (Jenkins and Elliott 2004; Moore and Cooper 1996; Sullivan 1993). This study suggests that associative stigma should be added to this list of demanding work features, as associative stigma can be considered a specific job stressor for mental health service providers, in analogy with stigma, which can be considered a stressor for service users (Rüsch et al. 2009).

Based on the results and their implications summarized above, we conclude that associative stigma deserves more research attention. Future studies should start with the development of a more sophisticated instrument for measuring associative stigma. Also, a more diverse range of outcome measures needs to be included when studying the consequences for service providers and users. In addition, researchers should pay attention to the intermediate processes that link associative stigma with service users’ well-being. Another research domain that remains relatively unexplored is that of the determinants of associative stigma. As not all professionals report the same level of associative stigma, it is important to determine what facilitates or impedes these experiences.

The topic of associative stigma has important policy implications. As far as we know, actions to improve this type of work-related well-being have not previously paid explicit attention to the issue of stigma, with the exception of educational programs aimed at destigmatizing the profession to make it more attractive for medical students (Cutler et al. 2009). However, this study suggests that stigma ought to be considered a real job stressor for this professional group and that its importance should not be ignored. Another policy implication regards the finding that associative stigma among professionals appears to be a stigma-enhancing mechanism among service users, which has been largely ignored; therefore, the role of professionals might have been underestimated. Initiatives aimed at reducing stigma experiences among service users should pay more attention to mental health professionals as both targets of the stigma associated with mental health care and contributors to the stigma experiences of mental health service users.

Supplemental Material

Supplemental_Material – Supplemental material for Associative Stigma among Mental Health Professionals

Supplemental material, Supplemental_Material for Associative Stigma among Mental Health Professionals by Mieke Verhaeghe and Piet Bracke in Journal of Health and Social Behavior

Footnotes

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is supported by a grant from the Special Research Fund of Ghent University and by the Flemish Research Council.

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