• Andy Salkeld

Broken the Stigma?

This piece is the student-generated dissertation of Andrew Salkeld, supervised by Dr Chanki Moon, as part of an MSc Psychology (Conversion) at Leeds Beckett University allowing Andrew to qualify as a Chartered Psychologist. At publishing, final results have not been awarded and feedback has not yet been provided.
Thank you to everyone who took part, showed interested and supported me whilst undertaking this. I could not have done any of this without you. Once again, thank you x

Abstract

Employees with mental ill health often report an unwillingness to engage with their condition at work for fear of negative attribution and not being considered equal. Stigma towards mental illness in the workplace is a major barrier to seeking treatment despite significant improvements in treatment methods. Understanding the nature of stigma towards people with mental illness will allow organisations to develop effective interventions to support their employees. This study asks 59 participants from professional services organisations in the UK to read a vignette describing an employee presenting with general anxiety disorder symptoms that included a mental illness diagnosis label, a physical illness diagnosis label or no label, and rate their affective, cognitive and behavioural stigma towards the employee as well as their perception of the affective, cognitive and behavioural stigma by others within their organisation towards the employee. Contrary to the initial hypotheses, diagnostic label did not impact upon stigma towards the employee, however perceived stigma was found to be significantly greater than actual stigma and that this was primarily driven by affective stigma.


Introduction

Mental ill health is estimated to have a global cost of c.$2.5 trillion and is projected to grow over the next two decades (Bloom et al., 2011). Within the UK mental ill health costs employers between £33bn and £42bn annually (Department of Health and Social Care, 2017). People with mental illness (“PWMI”) or who have previously had mental ill health contribute c.12% of UK’s gross domestic product, representing c.£225bn of the UK economy (Mental Health Foundation, 2016). Mental illness is part of our workplace with an estimated c.6% prevalence of depression amongst the working population, however only about half are receiving appropriate treatment (Kessler et al., 2008). Significant improvements in treatment have been made over the past decades and there are now many effective treatments (Christensen et al., 2010). There is also strong evidence suggesting correlation between longer periods of untreated symptoms and poorer life outcomes for PWMI (World Health Organization, 2001). So why, when there are effective treatments with clear evidence of their benefits and also evidence of poor outcomes from non-compliance, do PWMI still not seek treatment? The problem is one of stigma.


Mental illness stigma

Stigma within the workplace associated with mental illness is a major barrier to seeking treatment amongst PWMI (Fox et al., 2018). PWMI do not engage with their illness by trying to disguise their emotions (Mental Health Foundation, 2018) often driven by a fear of discrimination and shame (Peterson et al., 2011). One of the major drives behind the fear of disclosure relates to negative performance attributions and an inability to access appropriate accommodations (McLaren, 2004) within the workplace (Martin et al., 2014). This fear leads many individuals to not disclose their illness and to not seek help in a timely manner (Lasalvia et al., 2012), which can lead to poorer life outcomes for the individual (World Health Organization, 2001). Many of the people who may benefit from the improving quality of mental illness treatments opt not to start, or complete them if started, due to stigma (Corrigan, 2004). Recent studies have shown that PWMI have reported that the associated stigma within the workplace of mental illness is as bad, if not worse, than living with the illness itself (Stuart et al., 2012).


Considerable work into mental illness stigma has taken place over the past decade within the field of psychology. The tricomponent model of stigma discusses three primary mechanisms: stereotyping, prejudice and discrimination (Ottati et al., 2005) which have been empirically tested in practice (Martin, 2010). For example, a manager who believes PWMI are ineffective workers (stereotyping – cognitive component) may view a new PWMI employee negatively (prejudice – affective component) and thus may overly criticise the work produced by said employee even if it is of the same standard as produced by another employee (discrimination – behavioural component). However, this only considers the perspective of the stigmatiser and not the other components of stigma, as laid out by Fox et al.’s (2018) Mental Illness Stigma Framework. The other components are the perspective of the stigmatised individual and perceived stigma. The perspective of the stigmatised individual relates to stigma that has been experienced, such as through the mechanisms of described above (Wahl, 1999); anticipated stigma, which is the extent to which a person expects to be the target of these stigma mechanisms (Quinn et al., 2009); and finally internalised stigma, representing how much an individual endorses and perpetuates negative stigma beliefs of the self (Bos et al., 2013). Perceived Stigma is the only shared mechanism of stigma and represents the perceptions of societal or cultural beliefs towards PWMI (Griffiths et al., 2018). It is important to separate personal and perceived stigma into separate constructs (Griffiths et al., 2008) as they require different interventions.


Workplace interventions

Much of the research produced around mental illness stigma in the workplace is with the goal of lowering stigma to build more inclusive workplace cultures. Organisational culture shapes the attitudes and behaviour of employees (Schein, 2010) and therefore it is critical that the leaders who set the tone of the culture choose appropriate initiatives and interventions to support their employees. Supportive leadership and positive workplace culture have been shown to have a positive impact on PWMI employee recovery (Secker et al., 2003) and that those cultures which emphasise support and inclusion are positively correlated with positive well-being outcomes for all employees, not just PWMI (Marchand et al., 2013).


However, studies have found that many workplace interventions tend to focus on the individual PWMI (Martin et al. 2016) to address the perspective of the stigmatised. These interventions often function by promoting access to treatments, supporting workplace accommodations, or by equipping managers with knowledge and tools to support PWMI e.g., Mental Health First Aid Training. This places the responsibility on an individual to ‘seek help’ rather than considering the components of stigma that can be influenced and controlled by the employer e.g., stigma mechanisms and their contribution to perceived stigma. This idea of placing the responsibility on the individual within the organisation rather than addressing cultural factors is further demonstrated by a lack of inclusion of such topics within senior leadership education programs (Martin et al., 2015), further perpetuating this approach.


The two most effective interventions used to reduce mental illness stigma within organisations are education and contact (Corrigan et al., 2012). Education addresses stereotyping, the cognitive component of stigma, and involves raising people’s understanding of mental illness through presentations and other educational material. Through raising understanding, employees are less likely to endorse and perpetuate stigma related views and thus lowers cognitive stigma present within an organisation (Finkelstein et al., 2007). Contact approaches to stigma address the affective component, prejudice, and involve contact with people currently experiencing or who have previously experienced mental ill health. These interventions often involve meeting and listening to someone about their lived experience. Research shows that after a contact intervention, people are less likely to endorse and perpetuate both stereotyping and prejudice beliefs, which in turn reduces discrimination, and that those people are more likely to endorse positive beliefs about PWMI (Corrigan et al., 2012). A meta-analysis of stigma reduction interventions has shown both interventions produce positive improvements, but contact interventions were more effective overall (Corrigan et al., 2012).


However, contact interventions are often costly and labour intensive (Corrigan et al., 2006); requiring the payment of an individual to present, but also the time cost of employees attending the presentation. Within the private sector, where profit and cost-effectiveness are important, allocating appropriate resources to deliver successful interventions are crucial. As such, knowing how stigma develops and what stigma mechanisms may be manifesting within the workplace are important to deliver effective interventions.


Professional services

Much work has taken place within the UK to end all forms of mental illness stigma. Many campaigns such as “Ask Twice” and “Time to Talk” have been organised by the charity, Time to Change, to end mental illness discrimination (Time To Change, 2008). The Lord Mayor’s Appeal started ‘This is Me’ to support organisations to end workplace mental illness stigma and has now rolled this innovation out nationwide through partnership organisations. These interventions are primarily education based supported by limited contact interventions. The Mental Health Foundation recently published a report stating that mental illness stigma in the workplace can be driven by contractual agreements, with clauses referencing terminating employment contracts ‘if of unsound mind’ (Mental Health Foundation, 2018). At a seminar discussing this report one participant stated, “We need to target those industries that have a high amount of stress as priorities, for example, financial services…” (Mental Health Foundation, 2018, p. 11). Other participants echoed this sentiment stating, “Managers can put their colleagues under a lot of stress by putting them under pressure because they are not aware of how their actions can affect the mental health of employees”, and “Burn out is another issue for the public/third sectors…” (Mental Health Foundation, 2018, p. 12).

Professional service organisations are recognised as some of the most stressful work environments where considerable pressure is placed upon the employees to deliver high quality work in tight timeframes. Kelly Feeham, Service Director of Chartered Accountants Benevolent Association, a charitable organisation set up by the Institute of Chartered Accountants of England and Wales, stated; “32% of accountants feel stressed in their day-to-day life and a further 17% have been forced to take time off due to stress,” and “Accountancy can be a demanding profession, with our research revealing that 17% of past and present ICAEW members in the UK have taken time off due to stress” and “Workplace stress had caused 42% of respondents to consider resigning, while 40% had looked for a new job elsewhere. Nearly 14% had actually handed in their notice because of workplace stress” (Moore, 2015). Similarly, LawCare, a registered charity set up to support legal professionals and legal practices, recently published a report stating 23% of communications with the charity relate to stress and a further 25% relate to depression and anxiety combined (LawCare, 2020). Elizabeth Rimmer, CEO of LawCare stated; “…website traffic increased by 50% and we allocated more peer supporters and funded more counselling sessions last year than ever before,” highlighting the impact of stress in the legal workplace.

Stress has been shown to have a prognostic effect towards mental illness (Cole et al., 1954; Clum, 1976). Recently epidemiologic surveys have found psychiatric comorbidity correlations between stress, depression and anxiety (Gradus, 2017). Accountants, lawyers and other professional services employees could be at risk of developing mental ill health through prolonged exposure to stressful workplace environments. Any stigma mechanisms present within their workplace may in turn prevent them from seeking adequate help. Addressing any stigma present will likely require interventions and as such, knowing what stigma if any is present will allow the allocation of appropriate resources to support their employees and improve the overall workplace culture.


The current study

This study is designed to consider ‘controllable’ stigma towards PWMI from the perspective of UK professional services businesses. These businesses can influence the perspective of the stigmatiser and their contribution towards perceived stigma. This 3 (mental health, physical health, control) x 2 (actual stigma, perceived stigma) quantitative mixed experimental design considers the following three research questions.


Firstly, does the diagnosis of a common mental illness carry significantly increased stigma compared to a diagnosis of a common physical illness or no diagnosis when all conditions demonstrate the same symptomology? Hypothesis one is that such a diagnosis will carry significantly increased stigma when compared to either control.


Secondly, do people perceive that the diagnosis of a common mental illness carries significantly increased stigma, from others within their organisation, compared to a diagnosis of a common physical illness or no diagnosis when all conditions demonstrate the same symptomology? Hypothesis two is that such a diagnosis will carry significantly increased perceived stigma when compared to either control.


Lastly, is the stigma towards an individual with a diagnosis of a common mental illness significantly different from the perceived stigma held by others within the organisation? Hypothesis three is that there is no significant difference between actual and perceived stigma within the mental illness condition.


Method

This experiment and the three hypotheses were preregistered with Open Science Framework (Salkeld et al., 2021). This study was approved by Leeds Beckett University’s research ethics committee; reference 83503.


Participants

Participants were recruited through non-probabilistic cluster sampling through recruiting senior leadership team partners at professional services firms through the author’s professional network. These people acted as gatekeepers and were asked to facilitate recruitment within their organisation. Additionally, non-paid-promotion social media posts via LinkedIn were made to highlight the opportunity for individual professional services employees. Due to the sensitive nature of this topic, all communications referred to anonymity and confidentiality being maintained thoroughly throughout the study. No incentivisation was provided to individuals who chose to participate. All participants provided informed consent to participate and were fully debriefed upon completion. Incomplete responses and responses indicating that the respondent was not a professional services firm employee were discounted from the population. Participants were 59 adults (23 males) aged 24 to 60 years (M = 41.07, SD = 8.81) who self-reported as working within the professional services sector for between 1 and 40 years (M = 15.62, SD = 8.99). Additional demographic details were not collected to protect the identities of participants.


Materials and procedure

A vignette of a professional services employee who meets the criteria for DSM-V General Anxiety Disorder was created (see Appendix 1). The vignette adult was named ‘Sam’ and no gendered pronouns were used. Participants were randomly assigned to one of three experimental conditions based on the inclusion of a sentence referring to a recent diagnosis. Firstly, 1. Mental Illness Diagnosis included, “Sam has recently told you in confidence that they were diagnosed by their doctor with general anxiety disorder and are now medicated with antidepressants”. Secondly, 2. Physical Illness Diagnosis included, “Sam has recently told you in confidence that they were diagnosed by their doctor with diabetes and are now medicated with insulin”, acting as an alternate control. Finally, 3. No Diagnosis included no additional sentence, acting as a pure control. Participants were informed that they worked with Sam on a regular basis.


After reading the vignette, participants made stigma ratings. Given the focus on mental illness stigma within organisations, the three-factor model of the Managerial Stigma Towards Employee Depression Scale (Martin, 2010; Martin et al.,2015 ) was chosen as a suitable measure. The affective subscale contained six items relating to emotional responses to Sam within the workplace (α = 0.77). The cognitive subscale contained six items relating to negative thoughts relating to PWMI (α = 0.72). The behavioural subscale contained six items relating to work related actions and decisions (α = 0.75). To consider the perspective of the stigmatiser (Fox et al., 2018), each question was adjusted to refer to the vignette e.g., A1 “I feel comfortable dealing with depressed employees” was adjusted to read “I feel comfortable dealing with employees acting like Sam”. Then, to consider the perspective of perceived stigma, these adjusted questions were duplicated and adjusted to refer to “people within my organisation” e.g., A1 “I feel comfortable dealing with employees acting like Sam” was adjusted to read “People within my organisation feel comfortable dealing with employees acting like Sam”. Thus, the survey included 36 x 6-point Likert scale questions (strongly disagree to strongly agree) as detailed in Appendix 2. The perceived stigma questions were presented first with the order of the three blocks (affective, cognitive, behavioural), each of six questions, randomised. These were followed by the actual stigma questions with the order of the three blocks, each of six questions, randomised.


Data analysis

The majority of questions were phrased such that a higher score represented a higher level of stigma e.g., C2 “Employees like Sam are a liability to an organisation”. Eight questions were phrased in such a way that a higher score represented a lower stigma e.g., B4 “I would make temporary changes to the job to help an employee like Sam recover”. The questions PA1, PB3, PB4, PB6, A1, B3, B4 and B6 (see Appendix 2) had their score transposed such that one became six, two became fire, three became four etc. Following completion of the transposition above; mean values for each of the individual stigma subscales e.g., Perceived Affective Stigma, were calculated. Finally, totals for Total Perceived Stigma (“TPS”) and Total Actual Stigma (“TAS”) were calculated.


Shapiro-Wilk tests of normality showed that TPS and TAS across all three experimental conditions were normally distributed (p ≥ .06 in all cases), except for control condition TAS (W(22) = .880, p = .012). Shapiro-Wilk tests of normality showed that the affective, cognitive and behavioural components of perceived and actual stigma were normally distributed across all experimental conditions (p ≥ .103 in all cases), expect for mental health perceived cognitive stigma (W(18) = .880, p = .002), mental health actual cognitive stigma (W(18) = .891, p = .041), physical health actual cognitive stigma (W(19) = .855, p = .008), control perceived cognitive stigma (W(22) = .879, p = .012), control actual cognitive stigma (W(22) = .832, p = .002) and control actual behavioural stigma (W(22) = .790, p < .001). All normality test results are included within Appendix 3. Most parametric tests are considered reasonably robust to violations in normality assumptions (Pallant, 2016), therefore it was deemed appropriate to use parametric analysis techniques.


Results

To check for any relationships between the demographic subject variables, TAS and TPS ratings, correlation analyses were performed as highlighted in Table 1 below.

TPS was significantly positively correlated with TAS. Length of Service was significantly positively correlated with Age. No significant correlational relationships existed between the subject variables and the dependent variables. No control for demographics was required.


Hypothesis 1

A one-way independent groups ANOVA revealed no significant effect of the diagnosis type on actual stigma, F (2,56) = .11, p = .899 (See Appendix 4). Labelling the vignette’s symptoms as attributable to a mental health condition did not have a significant impact on the TAS ratings towards Sam by the individual participant. This result rejects our initial hypothesis.


Hypothesis 2

A one-way independent groups ANOVA revealed no significant effect of the diagnosis type on perceived stigma, F (2,56) = .73, p = .488 (See Appendix 5). Labelling the vignette’s symptoms as attributable to a mental health condition did not have a significant impact on the TPS ratings towards Sam by others within the organisation. This result rejects our initial hypothesis.


Hypothesis 3

A paired t-test showed that mental health TPS (M = 7.63, SD = 2.43) was significantly greater than mental health TAS (M = 6.12, SD = 1.37) such that t (17) = 3.702, p = .002 (See Appendix 6). The effect size of this difference is large (d = 0.77). Confirmatory post-hoc power calculations were performed to assess the application of the result to the target population based on the sample size, confidence and effect size (see Appendix 7). This result rejects our initial hypothesis, however, given this unexpected significant difference, it warrants further exploration into the stigma subscales.

Repeated measures ANOVAs within the mental health experimental condition revealed a significant difference between affective, cognitive and behavioural subscale components for both perceived stigma and actual stigma (see Appendix 9). Across both cases, affective stigma was found to be significantly greater than cognitive and behavioural stigma (p ≤ .003 in both cases). No significant difference was found between behavioural or cognitive stigma in both cases (p ≥ .462 in both cases).


Similar repeated measures ANOVAs were conducted within the physical health experimental condition and the control experimental condition (see Appendix 10 and Appendix 11) to assess whether this difference was consistent across all conditions. A similar patten of significantly greater affective stigma was found to be consistent across all experimental conditions for both actual and perceived stigma. These results support the three-factor (affective, cognitive, behavioural) model of stigma in line with Martin and Giallo (2016).


Discussion

These results, as set out in Figure 1 below, reject all three initial hypotheses and demonstrate that there is no significant difference in TAS or TPS associated with the diagnosis of mental or physical health condition or in a control. The results also demonstrate that perceived mental health stigma is significantly greater than actual mental health stigma and that both forms of stigma, perceived and actual, are primarily driven by affective stigma, which is significantly greater than cognitive and behavioural stigma. Whilst these results reject our initial hypotheses, they provide a preliminary basis upon which professional services firms could choose to base future mental illness stigma reduction interventions to support their members as discussed within the Practical implications section below.



The experimental results show that actual and perceived stigma towards a PWMI is independent of diagnosis. However, they have also shown that perceived stigma is significantly greater than actual stigma towards a PWMI and that in both in cases, this is primarily driven by affective stigma. With caution, it is important to recognise that the mean scores of all subscale stigma components within the mental health condition are below 3 (1.57 ≤ MHS ≤ 2.84) except for perceived cognitive stigma (MHS = 3.18). These are all below the scale mean (M = 3.5). Similarly, across the physical and control conditions, no individual subscale stigma component is greater than the scale mean (MCS < 3.5 in all cases). When combined, no score for either perceived or actual stigma across all experimental conditions (M ≤ 8.44 in all cases) is greater than the total scale mean (M = 10.5). A one-sample t-test showed that mental health TPS (M = 7.63, SD = 2.43) was significantly different than the Mean such that t (17) = -5.009, p < .001. Similarly, A one-sample t-test showed that mental health TAS (M = 6.12, SD = 1.37) was significantly different than the Mean such that t (17) = -13.55, p < .001. Both TPS and TAS were significantly lower than the total scale mean. These results suggest that participants disagree to somewhat disagree, with the statements about actual and perceived stigma towards PWMI within their organisations. These results are not conclusive for the target population due to the restricted sample size, however, provide a positive indication that stigma towards PWMI may be improving, warranting further experimental investigation.


The experimental results reject our initial hypotheses. These results suggest that there may be subject components influencing the results. Whilst no correlation was found between the subject variables and the dependent variables; there may be other subject variables beyond those analysed to consider.


Accountants, lawyers and other professional services workers are traditionally well educated; often requiring a bachelor’s degree prior to undertaking a professional qualification. As such, a higher level of knowledge and familiarity with basic symptomology and mental illness terms may be present, however this would need to be confirmed through further study. The vignette(s) of Sam describes DSM-V symptoms of general anxiety disorder. It has been shown that in certain cases stigma towards symptoms was greater when presented with a diagnosis (Matsunaga et al., 2016), but that stigma attitudes persisted towards the symptomology even without a diagnosis. These attitudes towards symptoms without diagnosis have typically been found in more extreme cases of mental illness e.g., schizophrenia, paranoia (Sugiura et al., 2001); but could impact upon the experimental results. Results have also shown that recovered mental illness patients also produced stigma attitudes and heightened social distance (Link et al., 1983). However, in certain cases of mental illness e.g., dementia, it has been observed that a diagnosis can actually result in lower stigma towards an individual, evoking sympathy and helping behaviours (Garrand et al., 2009). This could help explain the similarity in responses across the experimental conditions; where participants are responding to the symptoms, not the diagnosis, or that the diagnosis could be offsetting any increased stigma.


Interestingly these results oppose traditional personality traits found within certain professional services. Narcissism has been found present throughout certain accounting populations (Arikan, 2005) and has been found to be positively associated with mental illness stigma. Similarly, the competitive environments sometimes found present within firms leads to lower levels of agreeableness and extraversion which have also been found to be positively associated with stigma towards PWMI (Canu et al., 2008). It has been found that these personality traits can mediate with age and progression within the firms; with the exception of partners where a reversal occurs (Akers et al., 2014). The sample population (MAge = 41.07, MLength of Service = 15.62) indicates an older population where narcissistic view may have reduced, lowering the impact upon stigma towards PWMI. Equally, given the diversity present within these firms, higher levels off Agreeableness and Openness would be expected and these have been found to have negative relationships with stigma towards mental illness (Yuan et al., 2018) in certain populations.


These mediating factors of education, age and personality present several interesting opportunities for expanding this study. To further develop knowledge within professional services, it would be interesting to conduct this as a longitudinal study across the careers of members, combined with selective qualitative interviews. This could provide organisations with information on when and how stigma towards PWMI manifests within the population and also to understand the components of stigma not controllable by the organisation e.g., Experienced Stigma (Fox et al., 2018).


Outside of highly focused studies on specific industry sectors such as this one and similar studies e.g., within Healthcare (Knaak et al., 2017), limited studies have taken place to consider the impact industry sector has on mental illness stigma. Through considering the impact of industry sector and the associated personality traits of typical workers within each sector, it may be possible to develop more tailored interventions to reduce stigma and PWMI within each industry, resulting in more targeted and effective interventions.


Practical implications

The results demonstrate that should professional service firms wish to address stigma towards PWMI within their organisations, interventions should target perceived stigma and the subcomponent of affective stigma. Contact interventions have been shown to be more effective than education interventions (Corrigan et al., 2012) and provide a more targeted approach towards the affective component of stigma. Building upon Social Identity Theory (Tajfel et al., 1979) and the Model of Group Socialisation (Moreland et al., 1982), whereby marginal/former members are considered more “in-group”; a successful contact intervention could be one that takes place with a current or former professional services worker with current or previous experience with mental ill health. This could help demonstrate that mental ill health is an acceptable social “norm” (Cialdini et al., 1998) within professional services. To address perceived stigma is more complex as it relates to the perceptions of societal beliefs towards PWMI (Fox et al., 2018). As such, interventions will likely require demonstrating the repeated acceptability and support provided to current PWMI within the organisation, reducing the perception of stigma. These interventions could provide an effective targeted approach to addressing perceived and affective stigma within professional services organisations.


Limitations and directions for future research

One major limitation of this study is the sampling strategy and sample size. The sample size for experiments one and two restricts the applicability of the result to the target population. The result of experiment three, whilst applicable to the target population due to the strength of the effect size, would also be better supported with a greater sample size.

This study is also based on self-reporting and as such caveats around social desirability bias are important to recognise. Whilst such factors are often offset by conducting studies anonymously online (Kreuter et al., 2008) they can still play a part in self-reporting.

The vignette design also potentially limits the results as noted previously. Further studies should consider including an additional control condition where no symptomology of general anxiety disorder is included within the vignette and/or might also include a vignette where the individual previously demonstrated the symptoms but has now recovered. Should a connection be found between people being stigmatised even after recovery, this could further influence unwillingness to engage with mental illness within the workplace.


Conclusion

Employees with mental illness report hesitance to engage with their condition whilst at work for fear of being attributed negatively and not being considered equally to their peers (Martin et al., 2016). This is particularly important within professional services due to the high levels of competition within the workplace, increased levels of stress due to tight deadlines and the prognostic effect of prolonged stress towards developing mental ill health. These fears limit help seeking behaviours that may limit recovery (Barney et al., 2009).


This study finds that within professional service firms, perceived stigma towards a person with a mental illness diagnosis is significantly greater than the actual stigma towards them with the affective component being significantly greater than both behavioural and cognitive components in each case.


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