Is stigma present among mental health professionals?
Before answering this question, we need to examine more closely what stigma is . Stigma and stigmatizing attitudes are widespread. It consists of stereotyping and devaluing individuals based on their membership in a particular social group.
Individuals with a mental disorder, for example, are often associated with dangerousness, oddness, irresponsibility, incompetence, weakness of character, dependency, unpredictability, inferiority, and vulnerability. But not all mental disorders are equally stigmatizing. People with schizophrenia, for instance, are seen as more dangerous and unpredictable than people with depression. Similarly, a criminal record can be stigmatizing, regardless of whether or not the individual has a mental disorder. Individuals with a criminal record are often considered evil, mean, unintelligent, psychologically maladjusted, immature, inconsiderate, and dishonest. And again, some crimes are more stigmatized than others, such as violent crimes and sex crimes.
Fighting stigma in mental health in the healthcare sector
People can also be stigmatized for belonging to various groups with discriminatory characteristics. This could be the case for individuals served by the prison/forensic mental health network (SMPF), which includes people with mental health disorders admitted to prison mental health inpatient units or those who have been subjected to a court-ordered security measure of confinement or psychiatric monitoring. We call this latter option "forensic" because it involves a court-ordered measure, but outside of prison, that is, in an inpatient unit or mental health center within the civilian network. These are cases of individuals with a serious mental disorder and a criminal record. This is called simultaneous or multiple stigma .
What do we understand by stigma?
The Attitudes and stigma toward individuals with mental disorders have received increasing attention since the 1960s. For example, in 1963, Goffman defined stigma as an “attribute that is deeply discrediting and reduces its bearer from a complete and ordinary person to a singled-out and despised one.” Since then, many variations of this definition have been suggested.
Stigma consists of three components:
Stereotypes
They refer to beliefs or structures of "knowledge" about the characteristics and behaviors of a group of people. They are the cognitive component that underlies stigma and stigmatizing attitudes.
Prejudices
Understood as “the emotional reaction or feelings that people have toward a group or member of a group,” these constitute the affective component. For example, the stereotype of dangerousness can provoke feelings of fear or be experienced as anxiety. Prejudices toward people with a mental disorder include fear, pity, and anger, but, as mentioned, these can vary depending on the disorder. For example, most people feel pity for individuals with mental disorders, especially those with depression; however, they express unease, uncertainty, and fear toward individuals with schizophrenia and rejection toward individuals with drug and alcohol abuse. It is important to emphasize that prejudice involves an active evaluative response (cognitive and affective), which leads to a negative emotional reaction. This means that people can be aware of stereotypes but not necessarily endorse them. This is especially important when combating discrimination, the behavioral component of stigma.
Discrimination
Discrimination Discrimination is unfair or disloyal behavior toward a social group or its members (outgroup) or exclusively favorable behavior toward members of one's own group (ingroup). Discriminatory behaviors exist along a continuum ranging from subtle to overt, and when dealing with people with mental disorders, the most frequently described behaviors are denial of help, avoidance, segregation, and coercion. Other studies also mention rejection, social distancing, and exclusion.
The stigmatizers versus the stigmatized
It is also important to understand that there are different types of stigma. Therefore, we must distinguish between those who perpetrate stigmatization (i.e., the stigmatizer) and those who are stigmatized (i.e., the stigmatized). Public stigma refers to the reaction of the general population or large social groups (the stigmatizers) toward a smaller social group (e.g., the people served by the SMPF network—the stigmatized), internalizing stereotypes about them and acting against them. Self-stigma , or internalized stigma, on the other hand, refers to the extent to which an individual internalizes negative stereotypes and prejudices against themselves. The stigmatization of a group of people can lead to the internalization of stigmatizing beliefs. This, in turn, can affect recovery and negatively impact coping mechanisms for mental illness and commitment to treatment. Self-stigma has also been associated with more serious psychiatric symptoms and a history of incarceration and homelessness, reduced coping strategies, feelings of shame, guilt, anger, and distrust of others, and is a risk factor for recidivism.
Finally, there is the stigmatization among professionals, or professional stigma . Although mental health professionals are trained, knowledgeable, and experienced with people with mental disorders, research shows that they too are susceptible to the negative attitudes held by the general population. Mental health professionals appear to exhibit both explicitly positive attitudes and implicitly negative ones, which may reflect unconscious emotions related to mental illness.
Are there differences between professional disciplines?
In a study of Australian healthcare professionals, psychiatrists held more negative attitudes than general practitioners and clinical psychologists, and were generally more pessimistic about long-term outcomes than the general population. Another study showed that most medical professionals (including psychiatrists) perceived people with mental disorders as unpredictable, dangerous, lacking self-control, and aggressive, and had little expectation of recovery. Furthermore, several studies revealed that healthcare professionals exhibit a desire for social distancing comparable to that of the general population.
While mental health professionals are more willing to accept mental health centers in the community, they are equally socially distanced and agree that mental health centers degrade a residential area.
When comparing the attitudes of other groups, such as medical and nursing students, toward people receiving care in mental health facilities, nursing students held the least favorable attitudes. Among medical students, positive attitudes decreased with years of medical practice. According to the researchers, education and familiarity may play a significant role in shaping positive attitudes: women, older individuals, and those with lower levels of education were more pessimistic about the social integration of individuals with mental disorders, highlighting the value of ongoing awareness-raising and training in support skills for medical staff.
This has also been suggested by another group of researchers who found that individuals who had had contact with a person who commits or has committed a crime reported less negative attitudes toward this group, suggesting that interpersonal contact influences public attitudes. Regarding people served by the SMPF network, only a few studies have focused on professional stigma. Community Mental Health (CMH) professionals, for example, often mention stereotypical images of "offenders" and "dangerous criminals" when asked about people served by SMPF. Another study found that most of the public (including law enforcement, psychiatrists, and the community) believed that SMPF individuals would not voluntarily submit to treatment and opposed the idea of allowing this group to receive treatment in the community unless a relatively controlled community network was established. Finally, a small minority of professionals from low and medium security SMPF units reported maintaining negative attitudes such as recovery pessimism, pity, fear, anger, and a desire for social distancing.
What impact can stigma have?
The Stigmatizing attitudes toward people with mental disorders have been associated with negative outcomes such as reduced self-esteem, social isolation, chronic stress, delayed help-seeking, and loss of personal relationships . Similarly, a criminal record can have negative consequences, such as hindering access to services like housing and education, reducing employment opportunities, and diminishing social networks and support systems. Negative employer attitudes make it difficult for people with criminal records to find employment, while employment has been shown to decrease the likelihood of recidivism and increase the probability of successful reintegration into the community.
This means that stigma not only affects reintegration into society but could even influence future criminality . Regarding opportunities for reintegration, applicants with a history of both mental illness and criminal behavior were among the least acceptable candidates for employment. Interestingly, employers were more inclined to hire people with criminal records when the advantages of employing them were explained, but their opinion remained negative regarding people with mental illness. Furthermore, the presence of signs and symptoms of mental illness can increase the likelihood of being arrested. People identified by the system as having mental illness are more likely to be charged and less likely to receive a reprimand than those without a mental illness; and once in prison, people with mental illness spend more time incarcerated than those without.
Stigma among healthcare professionals can be even more damaging than that from the general public. 76% of people with chronic mental disorders consider their healthcare provider the most important person in their lives. Therefore, negative attitudes from healthcare professionals can have a significant impact on treatment outcomes and quality of life.
In the field of mental health and family planning (MHFP) care, stigma also appears to play a role in treatment adherence. To explain this, we need to examine more closely how MHFP care is organized. Broadly speaking, MHFP provides treatment to individuals with a mental disorder whose behavior has led, or could lead again, to offending.
In Spain, SMPF network care may prevail:
- As a security measure of internment or monitoring for individuals to whom the circumstances exempting them from criminal responsibility apply (in some cases they are referred directly to the SMC network).
- For individuals sentenced to prison who develop a serious mental disorder during their incarceration, the law dictates the best course of treatment, appropriate rehabilitation, and safe reintegration into society, and those served by the Mental Health and Family Planning (MHFP) network are not deprived of this fundamental right. Treatment focuses on individualized care pathways, including psychosocial and treatment needs and an assessment of the risk of recidivism. A prerequisite for rehabilitation is that individuals have the opportunity to demonstrate their willingness and competence to responsibly manage their condition in less restrictive environments. Therefore, mental health care is organized as a continuum of care, from highly specialized mental health care units (within prisons) to community mental health services (with support). This means that individuals, at some point in their treatment, must be referred from the MHFP network to care within the Community Mental Health (CMH) network. However, the SMC network is sometimes reluctant to accept patients from the SMPF network. Naturally, this creates a bottleneck in the organization of care within the SMPF network.
What can we do to combat the stigma towards people served by the SMPF network?
Within the research line Mental Health in the Penitentiary Setting (SMAP) belonging to the Research Group Etiopathogenesis of Severe Mental Disorders (MERITT) of the Sant Joan de Déu Research Institute , we have recently started a project to improve the link between care for SMAP and MHC: KOSTFOR-PRO ( Knowledge enhancement and stigma reduction – forensic mental health patients and MHC professionals ).
The project will consist of three phases:
- Understanding the training needs of SMC network care professionals in relation to the care of SMPF individuals
- Reduction of potential stigmatizing attitudes towards people from the SMPF network
- Development of an intervention to improve knowledge and reduce stigma.
The first aspect is considered necessary because specialist residency programs do not cover care within the Mental Health and Family Services (MHFS) network. This means that mental health professionals do not become familiar with or acquire knowledge about the individuals served by the MHFS network, their profiles, their functioning, their treatment needs, specific interventions, and the relationship between mental disorders and delinquency. This lack of knowledge and understanding can lead to stigmatizing attitudes, which brings us to the second aspect of the project. Together with a panel of national and international experts, we will develop a stigma assessment tool specifically designed to measure stigmatizing attitudes among mental health professionals toward individuals served by the MHFS network. Subsequently, we will evaluate the attitudes of professionals in both MHFS and Community Mental Health (CMH) care and investigate whether there are differences between services and disciplines. Finally, the results of phase 1 (training needs) and 2 (stigma) will be used to develop a tailored intervention aimed at improving knowledge about the care of SMPF people, and reducing possible stigmatizing attitudes.
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