Stigma toward people diagnosed with serious mental illnesses is a powerful force with pervasive impacts, some of which operate in subtle ways. In explaining the broad-reaching effects of stigma, Goffman (1963) asserted that persons who are “related through the social structure to a stigmatized individual…share some of the discredit of the stigmatized person to whom they are related.” Goffman suggested that there is an almost contaminative effect to the discrediting of stigmatized individuals that impacts those with whom they associate. This process, typically referred to as “associative stigma,” is generally thought of as applying primarily to the family members of people diagnosed with serious mental illnesses. There is evidence that family members often experience shame and family burden as a result of associative stigma (see Yanos, 2018, for review). Less frequently discussed, however, is the possibility that mental health professionals who work with people diagnosed with serious mental illnesses may also experience some degree of associative stigma, given the extent to which their lives are closely intertwined with those that they serve.
The way in which associative stigma might impact mental health professionals was explored in qualitative research I conducted with colleagues (Vayshenker et al., 2018) in which we asked 47 professionals who work with people diagnosed with serious mental illnesses about their feelings and interactions with community members in relation to their work. Participants discussed being frequently devalued, treated as if their work could be done by anyone (but would not want to be), and avoiding discussion of their work with people outside of the field as a result. A telling comment came from one participant, who shared: “I had family members once tell me that I had the job that others didn’t want, like a garbage collector. They all laughed about it.” Others talked about being frequently asked if they felt unsafe in their work, reflecting the commonly-held negative stereotype that people with serious mental illness are violent.
Building upon these qualitative findings, we developed a measure called the Clinician Associative Stigma Scale (CASS) which includes subscales tapping four areas that were expressed in the qualitative study: negative stereotypes about professional effectiveness, discomfort with disclosure, negative stereotypes about people with mental illness, and stereotypes about professionals’ mental health. We hypothesized that scores on this scale would be significantly associated with “burnout,” a syndrome characterized by emotional exhaustion, disengagement from one’s work, and cynicism about one’s ability to help one’s clients. We administered the scale, along with scales of burnout and quality of service provision to a sample of 473 social workers, psychologists, and counselors who identified that they worked with people with a serious mental illness (Yanos et al., 2017). We found that nearly half of participants endorsed most of these types of experiences as occurring “sometimes,” and that associative stigma was moderately but significantly associated with burnout, especially its “emotional exhaustion” component, as well as lower self-assessed quality of care. In another study we conducted with partners in Indiana, we replicated these findings and also found that scores on the CASS were also significantly associated with job dissatisfaction among mental health workers in the public sector (Yanos et al., 2020).
Some might question whether associative stigma should really be a concern to the mental health field given that its effects are much less impactful than the effects of the stigma that is directly experienced by people diagnosed with serious mental illnesses. However, we believe that there is evidence that how professionals respond to associative stigma affects not only them, but how they interact with diagnosed individuals as well. For one, burnout has been demonstrated to impact a range of client-level outcomes (see Yang & Hayes, 2020, for a review), including client engagement in treatment. This might occur because clients can tell when professionals are burned out and not putting their hearts into their work, and then “vote with their feet” by not showing up for services. We further speculate that interactions with clients can be impacted by associative stigma in ways that could impact the internalization of stigma among clients themselves. This can operate via subtle mechanisms in the ways that professionals communicate with clients when they are experiencing burnout, such as being overly critical. These behaviors can lead clients to feel ashamed of themselves and deepen beliefs that they are incapable of succeeding in pursuing their recovery goals.
What can be done about associative stigma? There has yet to be any research on this topic, but evidence from the study of supervision suggests that quality supervision can help. Research suggests that some aspects of quality supervision, potentially including encouraging exploration and selective self-disclosure (for example, in which a supervisor shares examples of experiencing and coping with associative stigma), can help to decrease burnout among community mental health practitioners (Knudsen et al., 2013), so it is plausible that exploring associative stigma in supervision may act to mitigate its effects. We encourage providers to talk about associative stigma with each other and to consider how it might affect their interactions with their clients. In addition, we believe knowledge about the recovery model (which emphasizes hope and personal choice) can help to protect against the effects of associative stigma. Although we have not directly studied the relationship between recovery model exposure and associative stigma, other research I have been involved with indicates that knowledge about recovery among clinical psychology trainees strongly predicted less endorsement of stigma (both negative stereotypes and intended social distance) among the trainees (O’Connor & Yanos, under review). This therefore suggests that greater attention to teaching the recovery model within social work, psychiatry and psychology training programs will benefit future clinicians as they move into the field and protect them against the corrosive effects of associative stigma.
Goffman, E. (1963). Stigma: Notes on the management of a spoiled identity. New York: Prentice Hall.
Knudsen, H., K., Roman, P., M., & Abraham, A., J. (2013). Quality of clinical supervision and counselor emotional exhaustion: the potential mediating roles of organizational and occupational commitment. Journal of Substance Abuse Treatment, 44, 528-33.
O’Connor, L., & Yanos, P. T. (2021). Training and individual predictors of attitudes toward serious mental illness among clinical psychology doctoral students. Manuscript under review.
Vayshenker, B., Deluca, J., Bustle, T., & Yanos, P. T. (2018). “As soon as people hear that word…”: Associative stigma among clinicians working with people with serious mental illness. Journal of Public Mental Health, 17, 20-28.
Yang, Y., Hayes, J. A. (2020) Causes and consequences of burnout among mental health professionals: A practice-oriented review of recent empirical literature. Psychotherapy, 57, 426-436.
Yanos, P. T. (2018). Written off: Mental health stigma and the loss of human potential. New York: Cambridge University Press.
Yanos, P. T., DeLuca, J. S., Salyers, M. P., Fischer, M., Song., J., & Caro, J. (2020). Cross-sectional and prospective correlates of associative stigma among mental health service providers. Psychiatric Rehabilitation Journal, 43, 85-90.
Yanos, P. T., Vayshenker, B., Deluca, J., & O’Connor, L. K. (2017). Development and validation of a scale of mental health clinicians’ experiences of associative stigma. Psychiatric Services, 68, 1053-1060.