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“Burnout” among mental health clinicians is a condition of great concern in psychology. Characterized by emotional exhaustion, disengagement from one’s work, and a cynicism about one’s ability to help one’s clients, it is unfortunately all-too-familiar to recipients of mental health services, who sometimes encounter professionals who seem to be “phoning it in” in their work. Much has been written about burnout, its causes and ways to manage it, but I’d like readers to consider a source of burnout that has rarely been considered in the literature: stigma toward people with mental illness.
What is the relevance of stigma to professional burnout? To understand this, it is first necessary to understand the concept of associative stigma. In his ground-breaking conceptual work on stigma, Erving Goffman proposed that stigma affects not only those who have negatively stereotyped traits or labels but also those who are “related through the social structure to a stigmatized individual.” Discussions of associative stigma usually focus on family members, who have been found to experience shame, reduced social status, and social avoidance from community members as a result. However, it is also plausible mental health professionals who work with people with serious mental illness (including people with disorders such as schizophrenia and bipolar disorder) may also experience associative stigma, albeit to a lesser degree.
The possibility that professionals can experience associative stigma was explored in a qualitative study conducted by Beth Vayshenker, Joseph DeLuca, and I, where we asked clinicians who work with people with serious mental illness 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, whose family members jokingly compared their work to that of a “garbage collector”- implying that working with people with serious mental illness is akin to managing human garbage. 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. I have experienced these types of expressions myself, even from well-meaning friends and relatives. As a result, I am generally reluctant to talk about my research or clinical work with someone unless I have good reason to believe that they have a genuine interest in people with serious mental illness. (Note that separate research conducted with community members has suggested that many community members do indeed devalue mental health professionals’ roles.)
How could experiences of associative stigma lead to burnout? We hypothesized that an awareness of associative stigma and the experience of a lack of support from friends and family that it is related to can contribute to a “wearing away” of one’s empathy. To explore this, Beth, Joe and I developed a structured scale called the “Clinician Associative Stigma Scale” (CASS), which included items like “When I tell them about the work that I do, people outside of the mental health field remark that the work must be ‘scary’,” and “When I am with friends who work outside of the mental health field, I am reluctant to discuss my work with people with serious mental illness.” We then administered the scale, along with scales of burnout and quality of service provision to a sample of over 450 social workers, psychologists, and counselors who identified that they worked with people with a serious mental illness. We found that nearly half of participants endorsed most of these types of experiences as occurring “sometimes,” and that associative stigma was indeed moderately but significantly associated with burnout, especially its “emotional exhaustion” component, as well lower self-assessed quality of care. Another study, currently in process with research partners in Indiana, has preliminarily found that scores on the CASS are significantly associated with both burnout and job dissatisfaction.
What are the implications of this work? There is no question that burnout is a major problem in the mental health field, and this research suggests that the effects of associative stigma need to be considered when finding ways to address it. Ultimately, burnout is important because it impacts client outcomes- leading clients to lack trust in the system, feel unsupported, and lose hope themselves. This means that discussion of associative stigma and its effects should be included in training programs, supervision, and other prevention methods with professionals to keep them from losing their ability to empathize with and support their clients. Although much work needs to be done in this area to start to undo the impact of associative stigma, we hope that the research that we have done is a start in this area.
