The Causes and Consequences of Stigma in Clinical Psychology

When I was a doctoral student in clinical psychology in the 1990s, I was exposed to a range of influences. On the one hand, I was connected with the recovery movement by a faculty member and met members of the lived experience community, which had a transformative impact on my career and interests.

However, at the same time, I took classes with faculty members who blithely echoed negative stereotypes about people with psychosis, such as that psychosis was biologically determined, that such individuals could not benefit from psychotherapy, and that outcomes such as working and having relationships were not possible for such individuals. I chose to reject these messages, but it was evident to me at that time that psychology had a deeply ingrained stigma problem.

Embedded in this problem was the expressed view that psychology had nothing to offer for persons experiencing psychosis and related problems, and that psychology’s contribution was to be found in its work with people with milder issues such as depression and anxiety, who could usually be helped in the (coincidentally more profitable) private sector.

Public-Sector Work

In fact, research supports that, after serving as an important part of the public-sector service system in the United States after World War II, since the 1980s, psychologists have become less and less engaged in public-sector work where people with psychosis and related conditions are usually encountered. In an article published in 2006, I, along with my colleagues David Roe and Paul Lysaker, speculated that subtly stigmatizing messages embedded within clinical psychology training was in part driving the reduction of psychology’s engagement in public-sector work.

One might wonder if, in the 2020s, with positive messages about the benefits of mental health treatment seemingly ubiquitous, there is still a stigma problem within clinical psychology training. Unfortunately, recently published research conducted by Lauren O’Connor and me demonstrates that stigma persists and elucidates some of the key factors that might be driving it.

In a study in which we surveyed both 87 training directors and 329 clinical psychology trainees, we found that people with psychosis were often seen as fundamentally “different” by clinical psychology trainees and that this “disidentification” was strongly associated with endorsement of intended social distance toward people diagnosed with psychotic disorders (a form of stigma).

Furthermore, and alarmingly, findings indicated that, although students who had trained in settings in which they were able to interact with people diagnosed with serious mental disorders were more likely to have adequate knowledge about mental health recovery and endorse less stigma overall, trainees who had only completed acute inpatient training placements actually had less recovery knowledge and endorsed more intended stigma. This is particularly concerning since these acute inpatient placements are “high-prestige” placements that are highly sought out by students and strongly encouraged by training programs, and in other settings might be the only training opportunities providing experience with people with psychosis.

In contrast, outpatient training settings, in which students might have the opportunity to work with people with psychosis who are living in the community over a longer period of time, are seen as lower prestige and sometimes actively discouraged, in my experience. I have come into contact with this directly myself as the coordinator of a psychology training program embedded within an Assertive Community Treatment team, where I have repeatedly learned that training programs discouraged or even forbade their students from accepting the training placement due to the view that it is perceived as a less desirable form of training, or because of openly stated “safety concerns.”

Another consequence of a culture of stigma within clinical psychology is that it marginalizes and negatively impacts those with experience of significant mental health problems within the field itself. This issue was recently addressed by two articles authored by Sarah Victor and colleagues, which found that, although mental health conditions (especially depression) are commonly experienced by clinical and counseling psychology professionals and trainees, the field does often not normalize or communicate acceptance of these conditions.

In a commentary that accompanied one of the articles that I was proud to co-sign, it was asserted that, as psychologists, we “have felt, feared, or witnessed adverse consequences related to stigma towards psychopathology in our professional training and careers.” I endorsed this both because I identify as someone who has a mental health condition and because I have witnessed this stigma in statements made by my academic and clinical peers in multiple instances over the years.

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Changing the Culture

What needs to be done to change the culture within clinical psychology training? For starters, programs need to address stigma among their faculty and supervisors. This stigma colors evaluations of prospective applicants and the frequently voiced (behind-closed-doors) view that students with mental health concerns lack the ability to be “competent” clinical practitioners. This needs to be communicated through leadership at programs and through consistent messaging from accrediting bodies.

Going further, to reduce the impact of training on stigma, programs need to start offering students “contact“ experiences with people with lived experience of psychosis who are in recovery in their training (by inviting people with such experiences to offer guest presentations in classes and the like). I have offered this to students in the courses that I have taught, and students have repeatedly attested to the transformative impact of these experiences.

Finally, in clinical training, there is evidence that harm is being caused by the field’s fixation on acute inpatient training placements, which appear to increase stigma due to the predominance of biomedical approach within those settings. Training directors need to join together to encourage students to balance such experiences with outpatient experiences in which they may see the full spectrum of functioning about people with serious mental health conditions, rather than only those that present when people are in an acute crisis.

Would these steps solve clinical psychology’s stigma problem? Most likely not, but I believe that they would represent a step forward in a worthy direction.