Expectations of Mental Illness Disclosure Outcomes in the Work Context: A Cross-Sectional Study Among Dutch Workers.

Purpose The decision whether to disclose mental illness at work can have important positive and negative consequences for sustainable employment and well-being. The aim of the study is (1) to examine workers' expectations of outcomes of mental illness disclosure in the workplace and to evaluate their expectations regarding which factors are of influence on these outcomes, (2) to identify distinct subgroups of workers, and (3) to characterize these subgroups in terms of personal, sociodemographic, and work-related characteristics. Methods In this cross-sectional survey study, a sample of 1224 Dutch workers was used. Latent Class Analysis (LCA) was used to identify classes of workers based on expected workplace mental illness outcomes. A three-step approach LCA was chosen to investigate whether the classes differed in characteristics. Results The majority of workers expected predominantly positive outcomes of workplace mental illness disclosure (e.g., being able to be one's authentic self; 82.4%), even though they simultaneously expected disclosure to lead to advancement-related discrimination (e.g., lower chances of contract renewal; or getting a promotion; 68.4% and 57%, respectively). Six distinct subgroups of workers were identified based on expected workplace mental illness disclosure outcomes: two positive classes (50.1%), two negative classes (33.3%), and two classes who indicated not to know what the outcomes would be (16.7%). Significant differences between the classes were found on personal experience, work-related association with mental illness, gender, educational level, and workplace atmosphere. Conclusion The disclosure process is complex, as most workers were optimistic (i.e., expected generally positive outcomes) whilst simultaneously expecting workplace discrimination. Subgroup differences in expectations regarding workplace mental illness disclosure outcomes were found.

Stigma, grief and depressive symptoms in help-seeking people bereaved through suicide.

BACKGROUND: The painful experience of mourning after suicide can be further complicated by the stigma surrounding suicide survival. We investigated how grief and depression influence the perception of stigma towards survivors in a sample of help-seeking persons bereaved through suicide. METHODS: Cross-sectional design. Information on sociodemographic variables and responses to the Stigma of Suicide Survivor Scale, Beck Depression Inventory (BDI) and Inventory of Complicated Grief (ICG) was collected from 240 people bereaved through suicide who consecutively accessed an online support initiative. RESULTS: Despite the strong correlation between ICG and BDI scores, the intensity of depressive but not of grief symptoms was related to perceived stigma towards survivors. Time since loss was also positively related to levels of perceived stigma against survivors. The links between depression and perceived stigma persisted after taking into account relationship with the deceased and other sociodemographic factors. LIMITATIONS: The main study limitations are the cross-sectional design, reliance on self-report measures, and the self-selection of the sample of people bereaved through suicide, seeking help through a website. Social support was not measured and the sample included a large proportion of women. CONCLUSIONS: Specific interventions designed for persons bereaved by suicide should consider that psychological distress and mourning are qualitatively different reactions to a suicide loss. The relationship among perceived stigma, depressive suffering and time elapsed since the suicide loss suggests the usefulness of closely investigating the experience of stigma in all people bereaved through suicide with depressive symptoms, even long after the event.

Stigma-related stress, shame and avoidant coping reactions among members of the general population with elevated symptom levels.

BACKGROUND: It is unclear whether mental illness stigma affects individuals with subthreshold syndromes outside clinical settings. We therefore investigated the role of different stigma variables, including stigma-related stress and shame reactions, for avoidant stigma coping among members of the general population with elevated symptom levels. METHODS: Based on a representative population survey, general stress resilience, stigma variables, shame about having a mental illness as well as avoidant stigma coping (secrecy and social withdrawal) were assessed by self-report among 676 participants with elevated symptom levels. Stigma variables and resilience were examined as predictors of avoidant stigma coping in a path model. RESULTS: Increased stigma stress was predicted by lower general stress resilience as well as by higher levels of perceived stigma, group identification and perceived legitimacy of discrimination. More shame was associated with higher perceived legitimacy. Lower resilience as well as more perceived stigma, group identification and perceived legitimacy predicted avoidant coping. Stigma stress partly mediated effects of resilience, perceived stigma and group identification on avoidant coping; shame partly mediated effects of perceived legitimacy on coping. Stigma stress and shame were also directly and positively related to avoidant stigma coping. Analyses were adjusted for symptoms, neuroticism and sociodemographic variables. CONCLUSIONS: Stigma may affect a larger proportion of the population than previously thought because stigma variables predicted secrecy and withdrawal among members of the general population with elevated, but overall mild symptom levels. Avoidant stigma coping likely has harmful effects, potentially exacerbating pre-existing psychological distress and undermining social networks. This highlights the need to reduce public stigma as well as to support individuals with subthreshold syndromes in their coping with stigma stress and shame reactions.

Shame, perceived knowledge and satisfaction associated with mental health as predictors of attitude patterns towards help-seeking.

Aims. To examine stigma- and knowledge-related barriers to help-seeking among members of the general population. Methods. In a representative survey of young to middle-aged Swiss adults (n = 8875), shame about a potential own mental illness, perceived knowledge about and satisfaction with one's mental health, psychiatric symptoms and attitudes towards help-seeking were assessed. Results. A latent profile analysis of all participants yielded two groups with different attitudes towards help-seeking. Relative to the majority, a one-in-four subgroup endorsed more negative attitudes towards seeking professional help, including psychiatric medication, and was characterized by more shame, less perceived knowledge, higher satisfaction with their mental health, younger age, male gender and lower education. Among participants with high symptom levels (n = 855), a third subgroup was reluctant to seek help in their private environment and characterized by high symptoms as well as low satisfaction with their mental health. Conclusions. Shame as an emotional proxy of self-stigma as well as poor subjective mental health literacy may be independent barriers to help-seeking. Interventions to increase mental health service use could focus on both variables and on those individuals with more negative views about professional help, in the general public as well as among people with a current mental illness.

Evolution of public attitudes about mental illness: a systematic review and meta-analysis.

OBJECTIVE: To explore whether the increase in knowledge about the biological correlates of mental disorders over the last decades has translated into improved public understanding of mental illness, increased readiness to seek mental health care and more tolerant attitudes towards mentally ill persons. METHOD: A systematic review of all studies on mental illness-related beliefs and attitudes in the general population published before 31 March 2011, examining the time trends of attitudes with a follow-up interval of at least 2 years and using national representative population samples. A subsample of methodologically homogeneous studies was further included in a meta-regression analysis of time trends. RESULTS: Thirty-three reports on 16 studies on national time trends met our inclusion criteria, six of which were eligible for a meta-regression analysis. Two major trends emerged: there was a coherent trend to greater mental health literacy, in particular towards a biological model of mental illness, and greater acceptance of professional help for mental health problems. In contrast, however, no changes or even changes to the worse were observed regarding the attitudes towards people with mental illness. CONCLUSION: Increasing public understanding of the biological correlates of mental illness seems not to result in better social acceptance of persons with mental illness.

Ingroup perception and responses to stigma among persons with mental illness.

OBJECTIVE: Mental illness stigma is common, but it is unclear why it affects some individuals more than others. We tested the hypothesis that the way persons with mental illness perceive their ingroup (people with mental illness) in terms of group value, group identification and entitativity (perception of the ingroup as a coherent unit) shapes their reaction to stigma. METHOD: Ingroup perceptions, perceived legitimacy of discrimination and reactions to stigma (educating or helping others, social performance, secrecy, social distance, hopelessness) were assessed among 85 people with mental illness using questionnaires and a standardized role-play test. RESULTS: Controlling for depression and perceived discrimination, high group value and low perceived legitimacy of discrimination predicted positive reactions to stigma. High group identification and entitativity predicted positive reactions only in the context of high group value or low perceived legitimacy of discrimination. CONCLUSION: Group value and perceived legitimacy of discrimination may be useful targets to help people with mental illness to better cope with stigma.

Strategies for disseminating evidence-based practices to staff who treat people with serious mental illness.

Evidence-based practices have not been widely implemented in real-world treatment settings for several reasons, including existing state laws, administrative policies, funding priorities, advocates' concerns, and program staffing. Dissemination strategies focus largely on program staffing and the question of why treatment teams that are responsible for assisting people with serious mental illness fail to use evidence-based practices. In a review of the research literature, two barriers to staff dissemination emerge: individual service providers lack the necessary knowledge and skills to assimilate these practices, and certain organizational dynamics undermine the treatment teams' ability to implement and maintain innovative approaches. Three sets of strategies are useful for overcoming these barriers and fostering dissemination: packaging evidence-based practices so that specific interventions are more accessible and user-friendly to service providers; educating providers about relevant knowledge and skills; and addressing the organizational dynamics of the team to facilitate the implementation of innovations. Research on dissemination is relatively new and is less well developed than the clinical and services research enterprise that has led to evidence-based practices. Implications for future studies are discussed.

Familiarity with and social distance from people who have serious mental illness.

OBJECTIVES: This study examined the effects of familiarity with and social distance from persons who have serious mental illness on stigmatizing attitudes about mental illness. METHODS: A total of 208 community college students completed three written measures about familiarity, perception of dangerousness, fear, and social distance. Path analysis with manifest-variable structural modeling techniques was used to test a version of a model in which familiarity influences the perception of dangerousness, which in turn influences fear, which influences social distance from persons with serious mental illness. RESULTS: Most of the participants reported experience with mental illness. Scores on the three written measures largely supported the path model. Correlations between the perception of dangerousness and fear as well as between fear and social distance were particularly strong. CONCLUSIONS: Approaches to social change that increase the public's familiarity with serious mental illness will decrease stigma. Further studies are warranted that focus on how contact between members of the general public and persons who have serious mental illness may be facilitated.

Three strategies for changing attributions about severe mental illness.

The effects of three strategies for changing stigmatizing attitudes--education (which replaces myths about mental illness with accurate conceptions), contact (which challenges public attitudes about mental illness through direct interactions with persons who have these disorders), and protest (which seeks to suppress stigmatizing attitudes about mental illness)--were examined on attributions about schizophrenia and other severe mental illnesses. One hundred and fifty-two students at a community college were randomly assigned to one of the three strategies or a control condition. They completed a questionnaire about attributions toward six groups--depression, psychosis, cocaine addiction, mental retardation, cancer, and AIDS--prior to and after completing the assigned condition. As expected, results showed that education had no effect on attributions about physical disabilities but led to improved attributions in all four psychiatric groups. Contact produced positive changes that exceeded education effects in attributions about targeted psychiatric disabilities: depression and psychosis. Protest yielded no significant changes in attributions about any group. This study also examined the effects of these strategies on processing information about mental illness.

Prejudice, social distance, and familiarity with mental illness.

In this study, the paths between two prejudicial attitudes (authoritarianism and benevolence) and a proxy measure of behavioral discrimination (social distance) were examined in a sample drawn from the general public. Moreover, the effects of two person variables (familiarity with mental illness and ethnicity) on prejudice were examined in the path analysis. One hundred fifty-one research participants completed measures of prejudice toward, social distance from, and familiarity with mental illness. Goodness-of-fit indexes from path analyses supported our hypotheses. Social distance is influenced by both kinds of prejudice: authoritarianism (the belief that persons with mental illness cannot care for themselves, so a paternalistic health system must do so) and benevolence (the belief that persons with mental illness are innocent and childlike). These forms of prejudice, in turn, are influenced by the believers' familiarity with mental illness and their ethnicity. We also discuss how these findings might contribute to a fuller understanding of mental illness stigma.

Motivational interviews as goal assessment for persons with psychiatric disability.

A necessary first step in the psychosocial treatment of persons with severe mental illness is helping them identify their goals. Unfortunately, goal assessment is often viewed as a categorical process in which individuals list needs for which they require services. Motivational interviews provide a more sophisticated approach in which persons specify the costs and benefits to each of the needs in the list. Benefits define the reasons why a person should pursue a goal; costs define barriers to achieving that goal. The basic mechanisms for understanding and implementing motivational interviews are summarized. Ways to circumvent barriers to motivational interviews are also discussed.

Interpersonal factors contributing to the stigma of schizophrenia: social skills, perceived attractiveness, and symptoms.

This study investigated the interpersonal factors (i.e., social skills, symptoms, perceived physical attractiveness) which are related to the stigma of schizophrenia. Social skills performance was assessed for 39 individuals with schizophrenia who participated in two role-plays with a confederate. Social skills ratings comprised 'overall social skill', 'meshing', 'clarity', and 'fluency' of speech, 'gaze', 'pleasantness' of conversation, 'involvement' in conversation, 'number of questions asked' during conversation, and 'perceived strangeness'. Symptomatology was assessed with the Brief Psychiatric Rating Scale. Ratings of perceived physical attractiveness were obtained by pausing the videotaped role-plays after the first 2s of the interaction. Ratings of 'social distance', based on an independent sample who observed the role-plays, were used as a proxy measure of stigma. The results showed that social distance was best statistically predicted by perceived strangeness, which in turn, was best statistically predicted by ratings of overall social skill. Negative symptoms appeared to have a more robust association with desired social distance than positive symptoms. Interpersonal factors, such as overall social skill, negative symptoms, and perceived strangeness, may contribute to stigma.

Performance improvement teams for better psychiatric rehabilitation.

Despite the promise of psychiatric rehabilitation, many programs fail to incorporate innovative rehabilitation practices into their day-to-day regimens. Performance improvement is an effective paradigm for helping agencies improve the quality of their programs. Four phases of performance improvement are reviewed in this article: organizing for change, preparing the environment, focusing the environment, and maintaining improvement. Implementing the four phases of performance improvement is illustrated in a case study. Methodological rigor of data generated by performance improvement teams is also discussed.

Mental health team leadership and consumers satisfaction and quality of life.

OBJECTIVE: The purpose of this study was to determine the association between leadership styles of leaders of mental health treatment teams and consumers' ratings of satisfaction with the program and their quality of life. METHODS: A multifactor model has distinguished three factors relevant to leadership of mental health teams: transformational leadership, in which a leader's primary goal is to lead the team to evolving better programs; transactional leadership, in which the leader strives to maintain effective programs through feedback and reinforcement; and laissez-faire leadership, an ineffective, hands-off leadership style. Research has shown transformational leadership to be positively associated with measures of the team's functioning, but the effects of leadership style on consumers is not well known. A total of 143 leaders and 473 subordinates from 31 clinical teams rated the leadership style of the team leader. In addition, 184 consumers served by these teams rated their satisfaction with the treatment program and their quality of life. RESULTS: Consumers' satisfaction and quality of life were inversely associated with laissez-faire approaches to leadership and positively associated with both transformational and transactional leadership. Moreover, leaders' and subordinates' ratings of team leadership accounted for independent variance in satisfaction ratings-up to 40 percent of the total variance. CONCLUSIONS: Leadership seems to be an important variable for understanding a team's impact on its consumers.

Lessons from social psychology on discrediting psychiatric stigma.

Advocacy, government, and public-service groups rely on a variety of strategies to diminish the impact of stigma on persons with severe mental illness. These strategies include protest, education, and promoting contact between the general public and persons with these disorders. The authors argue that social psychological research on ethnic minority and other group stereotypes should be considered when implementing these strategies. Such research indicates that (a) attempts to suppress stereotypes through protest can result in a rebound effect; (b) education programs may be limited because many stereotypes are resilient to change; and (c) contact is enhanced by a variety of factors, including equal status, cooperative interaction, and institutional support. Future directions for research and practice to reduce stigma toward persons with severe mental illness are discussed.

Changing attitudes about schizophrenia.

Research on the effectiveness of short-term education programs in changing societal attitudes about mental illness has been mixed. Education efforts seem to be mediated by characteristics of the program participants. This study determines whether the effects of a specially prepared, semester-long course on severe mental illness are mediated by pre-education knowledge about and contact with severe mental illness. Eighty-three participants who were enrolled in either a course on severe mental illness or general psychology completed the Opinions about Mental Illness Questionnaire before beginning the course and at completion. Research participants also completed a pre-and posttest of knowledge about mental illness and a pretest on their contact with people who have severe mental illness. The education program had positive effects on some attitudes about mental illness. Interestingly, the effects of education group interacted with pre-education knowledge and contact and varied depending on attitude. Participants with more pre-education knowledge and contact were less likely to endorse benevolence attitudes after completing the education program. Participants with more intimate contact showed less improvement in attitudes about social restrictiveness. Implications of these augmentation and ceiling effects are discussed.

Transformational and transactional leadership skills for mental health teams.

Many treatments for persons with severe mental illness are provided by mental health teams. Team members work better when led by effective leaders. Research conducted by organizational psychologists, and validated on mental health teams, have identified a variety of skills that are useful for these leaders. Bass (1990, 1997) identified two sets of especially important skills related to transformational and transactional leadership. Leaders using transformational skills help team members to view their work from more elevated perspectives and develop innovative ways to deal with work-related problems. Skills related to transformational leadership promote inspiration, intellectual stimulation, individual consideration, participative decision making, and elective delegation. Mental health and rehabilitation teams must not only develop creative and innovative programs, they must maintain them over time as a series of leader-team member transactions. Transactional leadership skills include goal-setting, feedback, and reinforcement strategies which help team members maintain effective programs.

The construct validity of empowerment among consumers of mental health services.

Subscales of the Empowerment Scale (Rogers, E. S., Chamberlin, J., Ellison, M. L., Crean, T., 1997. A consumer-constructed scale to measure empowerment among users of mental health services. Psychiatr. Serv. 48, 1042-1047) were examined to see whether they fit a model of consumer empowerment that distinguishes self- and community orientations. In addition, the relationship of these two superordinate factors to several psychosocial factors was examined. Thirty-five participants in a partial hospitalization program were administered the Empowerment Scale and measures of quality of life, social support, self-esteem, psychiatric symptoms, needs and resources, global functioning, and verbal intelligence. Analysis of the subscales of the Empowerment Scale yielded two factors consistent with self- and community orientations to empowerment. Correlational analyses revealed that the two superordinate factors were associated with different sets of psychosocial variables. A self-orientation to empowerment was significantly associated with quality of life, social support, self-esteem, and psychiatric symptoms. Community orientation was correlated with self-esteem, resources, verbal intelligence, and ethnicity. The implications of these findings for a model of consumer empowerment are discussed.

Recovery as a psychological construct.

Mental health advocates have proposed recovery as a vision for severe mental illness. The purpose of this study is to examine psychometric characteristics of a measure of the psychological construct. Thirty-five participants in a partial hospitalization program were administered the Recovery Scale and measures of quality of life, social support, self-esteem, consumer empowerment, psychiatric symptoms, needs and resources, global functioning, and verbal intelligence. Results showed the scale to have satisfactory test-retest reliability and internal consistency. Analysis of the concurrent validity of the Recovery Scale showed recovery to be positively associated with self-esteem, empowerment, social support, and quality of life. It was inversely associated with psychiatric symptoms and age. Implications of these findings for a psychological model of recovery are discussed.