Mental health provider-based stigma: Understanding ...

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Mental health provider-based stigma: Understanding the experience of clients and families Jennifer L.K. Charles

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Virginia Commonwealth University, School of Social Work, 1001 West Franklin Street, P.O. Box 842027, Richmond, 23284-2027, United States Accepted author version posted online: 25 Feb 2013.

To cite this article: Jennifer L.K. Charles (2013): Mental health provider-based stigma: Understanding the experience of clients and families, Social Work in Mental Health, DOI:10.1080/15332985.2013.775998 To link to this article: http://dx.doi.org/10.1080/15332985.2013.775998

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ACCEPTED MANUSCRIPT Article

Mental health provider-based stigma: Understanding the experience of clients and families Jennifer L.K. Charles Virginia Commonwealth University Ms Jennifer L.K. Charles MSW (Corresponding Author) Downloaded by [Jennifer Charles] at 09:56 25 February 2013

Email: [email protected] Affiliation 1: Virginia Commonwealth University, School of Social Work, 1001 West Franklin Street, P.O. Box 842027, Richmond, 23284-2027 United States Acknowledgments: My dissertation co-chair, Kia J. Bentley, for her unrelenting support and guidance in my doctoral education; for supervising this project and providing assistance in its reviewing findings. Also, Drs. Jennifer Manuel and Joseph Walsh for providing constructive feedback. Abstract That the general public commonly holds negative attitudes and beliefs towards persons living with mental illness is well-documented (Corrigan, Mueser, Bond, Drake, & Solomon, 2008; Rusch, Angermeyer, & Corrigan, 2005; Wahl, 1999). What is surprising is that some researchers have identified similar attitudes and beliefs held by mental health providers (Lauber, Anthony, Ajdacic-Gross, Rossler, 2004; Lauber, Nordt, Braunschweig, & Rossler, 2006; Nordt, Roosler, & Lauber, 2006). This less-understood phenomenon, provider stigma, is defined as the negative attitudes, beliefs, and behaviors that mental health providers possess and enact toward clients. The consequences of provider stigma are profound, yet efforts to address it must begin with intensive exploration of the concept and its experience. This paper describes an ethnographic

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ACCEPTED MANUSCRIPT content analysis (ECA) of client and family member-authored literature around the concept of provider stigma. The hope is that the outcome of analysis, a conceptual model involving five themes related to the lived experience of provider stigma, may be useful to social work practitioners, educations, and researchers:

Sensitizing practitioners to actions and attitudes

potentially perceived as less-than-helpful or harmful; to educators entrusted with preparing future mental health social workers; and for researchers further investigating the phenomenon, its

Downloaded by [Jennifer Charles] at 09:56 25 February 2013

consequences, measurement development, and intervention design. Keywords: mental health, provider stigma, lived experience

Introduction An insidious threat to the delivery of effective mental health services, provider-based stigmatization of persons living with mental illness is not a well-studied subtype of stigma. With particularly destructive consequences, including a fractured therapeutic relationship, less-positive treatment outcomes, blocked life goals, service avoidance, and nonadherence to treatment planning and recommendations (i.e.: Bjorkman, Angelman, and Jonsson; Lauber, Nordt, Braunschweig, and Rossler, 2006), provider stigma may potentially have a significant effect on the well-being and lives of persons living with mental illness. Since much of the research surrounding the stigma of mental illness is focused on self-stigma and public-stigma, a brief discussion of these often-studied subtypes is first presented, highlighting particular elements that may be helpful in understanding provider stigma. Stigma is defined by Link and Phelan (2001) as occurring when elements of difference labeling, stereotyping negative attribution, separation, status loss, and discrimination occur in a


ACCEPTED MANUSCRIPT context where there is a social power differential. Self-stigma is the awareness of public stigma, the acceptance of the stereotype’s legitimacy, and the self-application of the stereotype (Corrigan & Watson, 2002). Public stigma is defined as the negative attitudes of the general public toward individuals living with mental illnesses (Hayward & Bright; Rüsch, Angermeyer, & Corrigan, 2005). That the public generally holds these attitudes and beliefs is well-documented (Corrigan, Mueser, Bond, Drake, & Solomon, 2008; Rusch et al., 2005; Wahl, 1999). What is surprising is


that some researchers have identified similar attitudes and beliefs held by mental health providers (Lauber, Anthony, Ajdacic-Gross, Rossler, 2004; Lauber, Nordt, Braunschweig, & Rossler, 2006; Nordt, Rossler, & Lauber, 2006). Building on the definition of public stigma, provider stigma can be defined as the negative attitudes, beliefs, and behaviors that mental health providers possess and enact toward clients they serve, even unknowingly or subtly. The term of mental health provider is used to include mental health professionals: psychiatrists, psychologists, social workers, counselors, and psychiatric nurses; but also paraprofessional providers, mental health technicians, for example. The social justice implications of provider stigma, more elaborately described later, are profound and present a compelling research trajectory aimed at identifying the phenomenon, ascertaining incidence and prevalence, and designing interventions to alleviate provider stigma. Pursuing such an important task, we must first be armed with a clear, expansive, and detailed understanding of the phenomenon. In an effort to develop a rich description of the lived experience of provider-based stigma, this paper describes an investigation that utilizes ethnographic content analysis (ECA) a qualitative data analysis method pioneered by David Altheide (1987). The analysis focuses on client and family member-authored literature detailing experiences in the mental health service


ACCEPTED MANUSCRIPT environment and the perception of provider stigma. The outcome of this analysis is a conceptual model of five themes related to the lived experience of provider stigma from the client perspective; direct text quotations are provided for illustration. Practice implications of the model are suggested, along with implications for research targeting these social injustices in the lives of individuals living with mental illness.


Background Hayward and Bright (1997) argue that there are four possible explanations for the stigmatization of individuals living with mental illness. These four ‘justifications for stigma’ include the perception of dangerousness of a person with mental illness; the attribution of responsibility and blame for their illness; the chronicity of mental illness and its poor prognosis; and the disruption of social interactions. Corrigan and colleagues’ model of stigma development identifies these beliefs as stereotypes that may lead to prejudice (Corrigan, Mueser, Bond, Drake, & Solomon, 2008).

Prejudice is defined as the emotional and cognitive response of the

individual to stereotypes, which might include, for example, anger, disgust, and fear. For the purposes of this investigation, Corrigan and colleagues’ conceptualization of prejudice is used as a synonym for stigmatizing attitudes.

Stigmatizing behaviors, on the other hand, are the

behavioral manifestations resulting from stigmatizing attitudes. Corrigan and colleagues refer to stigmatizing behaviors as discrimination. These behaviors can be experienced as hostility, withholding help, and avoidance.

While these possible explanations of stigmatization of

individuals living with mental illness were originally proposed with regard to public stigma, it is here hypothesized that these stigmatizing attitudes and behaviors are relevant to the emergence


ACCEPTED MANUSCRIPT of provider stigma. For this investigation, Hayward and Bright’s four explanations of stigma: dangerousness, blame, chronicity, and disruption of social interactions serve as a rudimentary a priori coding protocol. Literature specifically related to provider based stigma is fairly scarce, compared to other stigma subtypes, but is briefly summarized, providing context for the current study. Mental health providers are members of the general public, citizens of the general population, and are


subject to the same influences of public stigma as any other citizen, including mass media. As a result, mental health providers often subscribe to the same stereotypes about persons with mental illness that are endorsed by the general public (Schulze, 2007). One of the most prevalent of emotions reported by mental health providers about those living with mental illness is fear (Overton & Medina, 2008). Other prejudices, including dislike, anger, and neglect are also endorsed (Penn & Martin, 1998). Providing evidence for the experience of provider stigma, Wahl conducted a study in 1999 involving 1,301 mental health service consumers who were surveyed about their experiences with public stigma and discrimination. Secondary follow-up interviews were conducted with 100 individuals who had participated in the larger survey, which produced findings related to provider stigma. Namely, 28 of 100 interview participants reported experiencing stigma from “mental health caregivers” (1999, p. 473). The question of interest to this author is: What specific attitudes and behaviors of mental health providers are perceived as stigmatizing by their clients? The current investigation, designed to answer this question, is an ethnographic content analysis of personal account literature authored by mental health service clients and/or their family members. The use of personal account narratives in understanding the stigma of mental


ACCEPTED MANUSCRIPT illness is suggested as a viable source of information about stigma (Hinshaw, 2007). While there are limitations to the generalizability of such narratives to the population of interest, as well as questions of accuracy and believability, the general consensus is that personal account literature is a potentially abundant source of information and insight about the experience of stigma. Ethnographic content analysis (ECA) is a qualitative approach to content analysis championed in the work by Altheide’s (1987).

The purpose of this particular content analysis is the


identification of themes arising from the expressed experiences of stigmatizing attitudes (client and family perception of prejudice by helpers) and the experience of stigmatizing behaviors by helpers (client and family perception of discrimination) – specifically as they are encountered in the context of the mental health service experience.

This study’s objective is as follows: 1. To gain understanding and identify important themes related to the experience of mental health service client’s and their families of stigmatization by helping professionals through the analysis of biographical and autobiographical texts. . It is by understanding the phenomenon, particularly how it is experienced first-hand by those most negatively influenced by it that we can develop measurements to ascertain presence and levels of provider stigma. As incidence and prevalence are understood, appropriate and effective interventions may be next on the research agenda to eradicate this threat to a socially just provision of mental health services.


ACCEPTED MANUSCRIPT Method A purposive sample of client and family-authored books was generated through a search of Amazon.com’s best-sellers, the largest online retailer of books. The search terms “mental health services, books, biography” were used and sorted in order of “Best Selling”. This type of search strategy is not uncommon in sampling literature for an ECA. Besel, Zimmerman, Fruhauf,


Pepin, and Banning (2009), for example, initially used a similar Amazon-based literature search in their ECA of bridal wedding advice literature. These authors, however, found that their search yielded much too many possible sources, and they opted for a systematic visit to a local book retailer, Barnes & Noble. Based on review of their descriptions, potential books were placed in order of probable relevance to the experience of provider stigma. The selection of books were identified from this list as appropriate for inclusion, as a result of meeting the following criteria: published within the last twenty years; the work is either a personal memoir, a collection of stories, or a family account; the principal character describes a diagnosis involving a major mental illness (bipolar disorder, schizophrenia spectrum disorder, or major depressive disorder); ‘mental health services’ mentioned in the title, abstract, or table of contents. A list of the first 10 books meeting these criteria was assembled; only seven books were analyzed, because thematic saturation being reached. Data collection and analysis were guided by Altheide’s (1987) work on ECA, consisting of “reflexive movement between concept development, sampling, data collection, data coding, data analysis, and interpretation” (p.68). Although sometimes used in combination with traditional content analysis (i.e. Neuendorf, 2001), in which data units are tallied for frequency data,


ACCEPTED MANUSCRIPT providing quantitative support to qualitative data (i.e. Silverman, 2009; Smith, et al., 1994), the present study does not take this second step, consistent with other’s use of ECA (i.e. Besel, et al., 2009; Gormly, 2004). ECA can be used in studies seeking to develop theory, but it is more oriented for description and definition (Gormly). Also referred to as an informal version of the constant comparative method, new information is compared to already existing information, (i.e Gale & Newfield, 1992, Strauss, 1987, as cited in Smith, Sells & Clevenger, 1994). A basic


initial coding protocol was employed guided by Hayward and Bright’s identification of stigma underpinnings, described previously. The author, who has professional experience in a public mental health service setting, including close individual clinical work with clients living with psychotic disorders was primarily responsible for data itemization and coding.

Further

qualifying the author for this analysis, the author engaged in qualitative data analysis-specific coursework at the doctoral level, as well as having previous qualitative data analysis experience. Each book’s narrative text deemed relevant to the study was unitized and coded into existing and emergent themes in a manner described by Silverman (2009) as an iterative process moving between the data and the classification system. As new data emerged that failed to fit into the initial framework, new categories were created.

The categories were reviewed, linked, and

recoded. Trustworthiness and dependability of the findings were strengthened through the use of constant comparison, including the use of multiple pieces of literature, and external review (specifically, consultation and review of the study’s method and findings with a senior social work faculty member with a 30-year history of mental health-related research).


ACCEPTED MANUSCRIPT Sample The sample of texts is briefly described here in Table 1. These books were read, analyzed, text elements were unitized, and thematically categorized. As thematic saturation was reached, no further narratives were incorporated into the analysis, consistent with practices typically utilized with qualitative data analysis (Creswell, 2007).


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Results and Discussion The following themes were identified as relating to client and family member’s experience of provider stigma: 1. Blame and shame 2. Disinterest, annoyance, and/or irritation 3. Degradation and dehumanization 4. Poor prognosis/fostering dependence 5. Coercion and lack of ‘real’ choice.


ACCEPTED MANUSCRIPT Each of these themes is discussed below, including direct quotations indicative of the identified themes.

Blame and Shame The theme of blame and shame emerged as particularly salient in the ECA of client and family authored literature about the experience of provider stigma. Namely, clients perceived their Downloaded by [Jennifer Charles] at 09:56 25 February 2013

mental health providers as blaming them for their difficulties, the illness they experience, and for less-than-expected progress in treatment – in addition to being shamed as ‘less-than’ as the result of having a mental illness. The concepts of blame and shame, although distinctively different, have been combined categorically in this model of provider stigma. These concepts are briefly defined here and the case for combination is made. Blame is a reaction elicited when a person with a mental illness is thought to be morally responsible for their difficulties - that there is a moral deficit or deviant behavior associated with having a mental illness that could be controlled or mediated by the individual’s character or will (Hinshaw, 2007). Shame, on the other hand, is a reaction to the presence of mental illness evoked when there is an understanding that there is something inherently different and imperfect about the condition, in this case, having a mental illness. The difference is that the person who is to blame has morally or behaviorally caused the mental illness, whereas the person is shamed for being imperfect, having a mental illness.

Taking the distinction further, Scambler (2009)

differentiates between stigma and deviance – stigma implying an ontological deficit (inherently different), while deviance is a moral deficit (‘bad’ behavior) – stigma elicits shame and deviance blame (p. 450).


ACCEPTED MANUSCRIPT With this distinction in mind, the experience of blame can be most simply described as the attribution of responsibility for causing and controlling the display of the symptoms of mental illness. The following quotation, written by the mother of a young woman struggling with mental illness, is indicative of the experience of blame. “I was no longer her loved and trusted mother, but often seen as ‘the enemy’ (a view sometimes clearly shared by ward staff).” (Varley, 2007, pg. 95). Underlying the theme of blame is the helper’s perception that the client is


behaviorally responsible for the presentation of symptoms. Referred to by Hinshaw (2007) as a crucial attributional dimension relevant to the stigmatization of mental illness, controllability, or the ability of the individual to exert personal control over behavior, results in the perceiver’s blame of the client [or family member] (p.32). This element of stigmatization is not singularly associated with the experience of provider-based stigma. Rather, there is significant evidence that when attributions about controllability are associated to deviant behavior, blame and hostility are typically the result, no matter the role of the perceiver (i.e. Weiner, Perry, & Magnusson, 1988). An additional illustrative quotation comes from the experiences of a middleaged male writing about his experience in an in-patient setting for depression, in which he perceived blame related to the presentation of depressive symptoms: “One further difficulty was that each member of staff had their own ideology. Some would be ‘cruel to be kind’; a sort of pull yourself together approach.

Some were kind and tender and some were rude and

unapproachable. One of them called me a ‘lazy c**t’” (Short, 2007, p. 25). Shame, as previously differentiated from blame, implies an inherent imperfection in the person with mental illness. Shame refers to ‘you should feel bad and have less social status because of having a mental illness.’ The following quote, located in one of the included texts (Schiller &


ACCEPTED MANUSCRIPT Bennett, 1996) describes an interaction between a client and a nurse with whom was entrusted her care on an inpatient mental health unit. “Everyone, it seemed, had simply decided I was a problem that had to be solved. So everyone was extra tough with me…‘Stop feeling sorry for yourself,’ she barked in my door when I was sitting on my bed one day crying. ‘You’re acting like a chronic mental patient’” (p. 145). These concepts are combined thematically in this conceptualization of the experience of


provider stigma because they often coexist with regard to mental illness.

Additionally, the

distinction between shame and blame is often fuzzy, mostly because it is based on a subjective attribution of responsibility and controllability. Since the perceiver of provider shame and blame is not likely to actually know whether their provider harbors beliefs about inherent imperfection (and resulting shame) or behavioral culpability (thus blame), these categories are combined because they both result from misperceptions of illness responsibility and controllability.

Disinterest, annoyance, and/or irritation Another thematic category that emerged from the text analysis was disinterest, annoyance, and/or irritation. Narratives revealed the common perception of provider’s being uninterested in client and family concerns, as well as annoyance with requests for assistance or information. In addition, irritation was perceived by clients and/or families in response to requests for service, attention, or information. The following quotation is indicative of perceived provider disinterest, displayed through inattention and inaccessibility. “Later, I saw the scene that became very familiar, with the nursing staff in the office, behind the reception desk and with the door shut, chatting together” (Varley, 2007, p.97) Another quote, included next, illustrates the client’s


ACCEPTED MANUSCRIPT perception of their mental health provider - “I recall a nurse standing by irritated and impatient…”(Varley, p. 96). Provider disinterest, annoyance, and/or irritation were combined into one category as they were all perceived attitudinal characteristics that influenced the provider’s availability for client and family support and/or information.

Degradation and dehumanization


The next theme emerging from this ECA of client and family narratives is degradation and dehumanization. The experience of degradation is described as being treated as if they were of lower social status. This concept is related to the experience of dehumanization, which is to deprive one of human qualities, personality or spirit. These two experiences have been linked in the literature, with authors arguing that “being treated with subtle disrespect, condescension, neglect, and everyday thoughtlessness can leave us feeling degraded, invalidated, or demoralized, outcomes that we argue have implications for our experience of ourselves as human” (Bastian & Haslam, 2011, p. 295). Furthermore, dehumanization and denial of human uniqueness has been linked to perceptions of others as childlike – a key feature of the fostering dependence theme of provider stigma, based in ideas of paternalism. The following quotation, identified as a data unit in this ECA, is indicative of the experience of provider-based degradation. “The nursing staff would talk about me, in front of me. Their descriptions of me were often in conflict with my experiences” (Short, 2007, p. 24). Discussing clients and their care in front of clients, without involving them, places them in a social position that is lower than the provider – it implies that the client’s voice is not as important or accurate as the provider’s. The next quotation is illustrative of the experience of dehumanization, with its author distinctly


ACCEPTED MANUSCRIPT mentioning their very humanity being in question. “At the time I accepted it [how they were being treated]. When you are that low you don’t think you deserve to be treated like a human being” (Ockwell & Capital Members, 2007, p. 49).

Poor prognosis/fostering dependence The next theme identified in this ECA was that of poor prognosis and a fostering of Downloaded by [Jennifer Charles] at 09:56 25 February 2013

dependence. The idea that persons with mental illness are like small children and need to be taken care of is not a new stereotype associated with mental illness. Previous commentary and research has identified poor prognosis and dependence as two stereotypes regarding persons with mental illness held by the general population (i.e., Hayward & Bright, 1997; Hinshaw, 2007). The belief of poor prognosis refers to the idea that persons with mental illness will not recover, improve, and/or achieve life goals to which the average man or woman aspires.

Fostering

dependence, related to the assumption of poor prognosis, is the desire to promote in individuals with mental illness dependence on mental health services, support services, and medication. This belief is often predicated on the belief that since there is such a poor prognosis, it is for the client’s own good that they do not set their goals too high, nor stray too far from the safety of support services. The following three quotations, taken from the analyzed narratives, represent the themes of poor prognosis and fostering dependence. “Taking risks is usually seen as something to be avoided by people with mental illness, since it causes stress that may result in a ‘relapse.’” (Ruether, 2010, p. 173). “The staff doesn’t encourage us to do anything. If we spent the rest of our lives here, that would be just fine with them” (Flannery & Glickman, 1996, p. 119). “‘Schizophrenia is a very serious illness’ he said. ‘It may be a very long time – if ever-


ACCEPTED MANUSCRIPT before she will get better. She will probably never be able to live on her own again. It would be better for both of you if you faced facts’” (Schiller & Bennett, 1996).

Coercion and lack of ‘real’ choice The final theme emerging from data analysis is coercion and lack of ‘real’ choice. Coercion occurs when a mental health service client’s choices are externally influenced by the provider Downloaded by [Jennifer Charles] at 09:56 25 February 2013

and the service provision environment. The provider’s influence on a client extends beyond just the use of persuasion or threats, but also includes the use of their socially ascribed power and influence (Lidz, Mulvey, Arnold, Bennett, & Kirsch, 1993). The thematic element of the lack of a real choice reflects the client’s experience of making decisions about their treatment and lives without having access to all possible alternatives.

Medication adherence, voluntary versus

involuntary commitment, and utilization of supported housing versus independent living are examples of the types of choices that may leave the client feeling as if they have made a decision without being afforded all possible options. The lack of real choices as a theme of provider stigma is in direct contrast to one of the key elements in a recovery-oriented mental health service environment.

Jacobson and Curtis (2000), whose noteworthy work on the

conceptualization of recovery and its implementation in service settings nationwide, argue that “a recovery orientation includes emphasis on choice, a concept that encompasses support for autonomous action, the requirement that the individual have a range of opportunities from which to choose and full information about those choices…” (p. 3). If clients and families are not being offered real choices, the recovery-orientation to mental health care is not being achieved.


ACCEPTED MANUSCRIPT The experience of these elements, in the context of provider stigma, represent barriers to building effective therapeutic relationships. Coercion and a lack of real choice are related to feelings of provider mistrust, less positive appraisals of providers, less likelihood of accepting a psychiatric diagnosis, and less likely to see hospital admissions as necessary (Rogers, 1993). This theme may also be linked to other identified themes in the experience of provider stigma – specifically poor prognosis and fostering dependency, degradation and dehumanization, and even


provider annoyance and irritation. As illustration of the theme of coercion, this quotation from Schiller and Bennett’s (1996) narrative describes the perception of provider coercion: “My doctor on the unit and the social worker congratulated themselves. Their plan had worked. My bad behavior had turned out to be just that – bad behavior. Their threats and entreaties had pushed me into getting ‘better’” (p. 165). The following two quotations are reflective of the theme of coercion lack of real choice, the second specifically dealing with coercion by force. “…I was puzzled by the language of need to make [my son] ‘medication compliant.’ If you experience a drug as helpful, you don’t have to be made ‘compliant.’ Your own experience makes you willing to take the drug” (Ruether, 2010, pg. 130). “I refused medication and I was held down and injected by six staff. What I feel really strongly about is that no one gave me a choice… but no one said if you don’t take the medication we will have to force you…” (Ockwell & Capital Members, 2007, p. 49).


ACCEPTED MANUSCRIPT Implications and Limitations The identified themes of client and family experience of provider stigma, discussed above, form the conceptual model of provider stigma. This model identifies five themes related to the client and family experience of provider-based stigmatization. These themes include blame and shame; provider disinterest, annoyance and/or irritation; degradation and dehumanization; poor


prognosis/fostering dependence; and coercion and lack of ‘real’ choice. This model indicates that a provider’s negative attitudes, beliefs, and behaviors toward clients are perceived by clients and their families and negatively influence the helping relationship, satisfaction with the service receipt experience, and perhaps even treatment outcomes. It is also evident from this analysis that some of these attitudes, beliefs, and behaviors are being displayed by providers in a manner that may not reflect a conscious decision. For example, encouraging a client to have more realistic expectations of their ability to work full-time, the provider motivated by a desire to protect the client, according to this model, can be interpreted by the client as an attitude assuming poor prognosis, fostering dependence, and also a lack of ‘real’ choice regarding life decisions. Consequentially, if these attitudes, beliefs, and/or behaviors are unconscious, this conceptual model may be useful in sensitizing practitioners in mental health practice.

If

practitioners are educated about the possible client and family interpretation of their attitudes, beliefs, and behaviors, they may be more conscientious in their practice, avoiding these unconscious threats to the helping relationship. Knowing that provider’s attitudes and behaviors are perceptible to clients and families, the consequences of these stigmatizing attitudes become a concern. Research has indicated that


ACCEPTED MANUSCRIPT provider attitudes about clients have an influence on therapeutic outcome measures (i.e. Holmqvist, 2000).

If providers hold negative opinions about their clients with psychotic

disorders, Holmqvist’s study identified a resulting decrease in positive outcome measures. Clearly, if the field seeks to provide effective and efficient mental health services to clients who live with serious mental illnesses, attitudes and beliefs about the client influence treatment success and must therefore be attended to in practice and research. The negative influence of


provider stigma poses an injustices to our clients – they are being provided services that are less helpful than they could be, solely on the basis of mental illness. This social injustice requires continued investigation, discussion, and critical self-reflection on the part of mental health service providers.

The conceptual model’s creation has implications for social work research,

namely that it may be useful in guiding future inquiry on provider stigma, clarification of the concept, and measurement development. For example, future research should test the usefulness of this model to understanding provider stigma with a larger population of client’s and families. Also, adjustments and revisions to the model that take into account the provider’s training, discipline, and experience in mental health services would also be useful – as these factors likely influence the client-provider relationship and perceptions of provider-based stigmatization. In addition, the development of a self-assessment measurement instrument to ascertain presence and degree of provider stigma for use by mental health providers is the anticipated topic of the author’s dissertation project. The conceptual model that has emerged in this ECA provides the thematic categories to be used in item development, a key step in the measurement development process (DeVellis, 2003). The developed measure will also require validation of psychometric properties, and even perhaps an investigation of its usefulness as an intervention to reduce the


ACCEPTED MANUSCRIPT client and family’s experience of provider stigma. Research focused on developing interventions targeting the different themes of provider stigma is another possible avenue for future investigations, however, more work clarifying the concept of provider stigma and this study’s conceptual model are more immediately implied as research next-steps. This model of the experience of provider stigma has implications for social work practice, including direct work with clients, professional supervision, and continued professional


development. A client’s past experiences of provider stigma quite likely have an influence on their current relationships with helping providers. Social workers in direct mental health practice may find this model useful to engage clients in discussion about previous and current perceptions of provider-based stigmatization. In fact, by initiating a discussion of provider stigma, social workers can encourage a client’s self-advocacy as well as model the confrontation of difficult subject matter without negative personal or professional consequences. In addition, this model may be useful in the supervision of mental health social workers, as well as in continued professional education and development. This model could be used by supervisors in individual or group supervision to initiate the self-appraisal of clinicians and of the agency as a whole. Inservice trainings that address the stigmatization of mental illness may also find incorporation of the model helpful in targeting the subtleties of mental health provider-based stigma. There are limitations to this study that influence the use of its findings in future research projects. First, the generalizability of this study’s findings is unknown, which is not in and of itself a limitation, but rather something to necessarily consider in future research efforts that use the conceptual model. For example, it is quite possible that the experience of mental health consumers and their families who choose to write memoirs about their interactions with mental


ACCEPTED MANUSCRIPT health service settings are not uniformly representative of the countless other consumers and families who do not publish their experience. While a number of the texts used in this analysis were self-published, showing no real evidence of editing, and quite raw in detail, the experience of one who decides to produce such a work may be different than those who refrain. The decision to document and publish one’s experience may be influenced by education- level, feelings of a stigmatization’s legitimacy, or even self-stigma and fear of being public about one’s


mental health challenges. Therefore, future research should apply the model to other samples with sensitivity. Another possible limitation, some of the narratives used in this analysis were portions of edited books, for example Hardcastle, Kennard, Grandison, and Fagin (2007). It is therefore possible that the narratives were edited in some way, or not purely the client or family member’s voice. Additionally, there were limited opportunities to enhance this qualitative study’s rigor. Although external review was employed, along with the professional experience of the author as an inpatient psychiatric social worker, other methods of enhancing rigor would have added trustworthiness to the study’s findings. Member checking was not possible, as the authors of these pieces were not personally known and in some cases were anonymous. However, despite these limitations, the rich description of provider stigma and the conceptual model will likely prove useful to the social work practitioner, educator, and to researchers.

Concluding thoughts The experience of provider-based stigma by mental health service clients and their families poses a threat to the provision of effective services. For this reason, as well as the commitment


ACCEPTED MANUSCRIPT of the profession to fighting social injustice, this phenomenon merits investigation to aid in understanding, assessment, and eradication. This study, an ethnographic content analysis of client and family authored personal account literature, provides a rich description of the experience of stigmatization emanating from mental health providers. In summary, the themes identified include: blame and shame; provider disinterest, annoyance and/or irritation; degradation and dehumanization; poor prognosis/fostering dependence; and coercion and lack of


‘real’ choice. Useful in sensitizing social work practitioners to the client and families perception of often unconscious attitudes, beliefs, and behavior may help to mitigate the display and thus the experience of provider stigma. In addition, the model has implications for research, namely measurement development of the construct of provider stigma, evaluation of the use of a selfassessment measure for providers as a method of intervention, and the development of other interventions designed to address and ameliorate provider-based stigma.

References Altheide, D.L. (1987). Ethnographic content analysis. Qualitative Sociology, 10(1), 65-77. Bastian, B., & Haslam, N. (2011). Experiencing dehumanization: Cognitive and emotional effects of everyday dehumanization. Basic and Applied Social Psychology, 33(4), 295-303. doi: 10.1080/01973533.2011.614132 Bessel, A., Zimmerman, T.S., Fruhauf, C.A., Pepin, J., & Banning, J.H. (2009) Here comes the bride: An ethnographic content analysis of bridal books. Journal of Feminist Family Therapy, 21(2), 98-124.


ACCEPTED MANUSCRIPT Boyles, D.C. (2004). My punished mind: A memoir of psychosis. Lincoln, NE: iUniverse, Inc. Bjorkman, T., Angelman, & Jonsson, M. (2008). Attitudes toward people with mental illness: A cross-sectional study among nursing staff in psychiatric and somatic care. Scandinavian Journal of Caring Sciences, 22, 170-177. Corrigan, P.W., & Watson, A.C. (2002). The paradox of self-stigma and mental illness. Clinical


Psychology: Science and Practice, 9(1), 35-53. Corrigan, P.W., Mueser, K.T., Bond, G.R., Drake, R.E, & Solomon, P. (2008). Principles and practice of psychiatric rehabilitation: An empirical approach. New York: The Guilford Press. Creswell, J.W. (2007). Qualitative inquiry and research design: Choosing among five approaches (2nd ed.). Thousand Oaks, CA: Sage Publications. DeVellis, R.F. (2003). Scale development: Theory and applications (2nd ed.). Thousand Oaks, CA: Sage Publications. Glickman, M., & Flannery, M. (1996). Fountain House: Portraits of lives reclaimed from mental illness. Center City, MN: Hazelden Publishing. Gormly, E. (2004). Peering beneath the veil: An ethnographic content analysis of Islam as portrayed on The 700 Club following the September 11th attacks. Journal of Media and Religion, 3(4), 219-238. Hardcastle, M., Kennard, D., Grandison, S., & Fagin, L. (Eds.). (2007). Experiences of mental health in-patient care: Narratives from service users, carers, and professionals. New York, NY: Routledge.


ACCEPTED MANUSCRIPT Hawthorne, W. (2009). Billy: One family's insane journey through the Virginia mental health system. Chipmunkapublishing. Hayward, P., & Bright, J.A. (1997). Stigma and mental illness: A review and critique. Journal of Mental Health, 6(4), 345-354. doi: 10.1080/09638239718671 Hinshaw, S.P. (2007). The mark of shame: Stigma of mental illness and an agenda for change.


New York, NY: Oxford University Press. Jacobson, N., & Curtis, L. (2000). Recovery as policy in mental health services: Strategies emerging from the States. Psychosocial Rehabilitation Journal [Electronic version]. Retrieved from: http://fivecountymh.org/Docs/JacobsonCurtis%202-5-99%20fin.pdf Lauber, C., Anthony, M., Ajdacic-Gross, & Rössler, W. (2004). What about psychiatrists’ attitude to mentally ill people? European Psychiatry, 19, 423-427. doi: 10.1016/j.eurpsy.2004.06.019 Lauber, C., Nordt, C., Braunschweig, C. & Rössler, W. (2006). Do mental health professionals stigmatize their patients? Acta Psychiatrica Scandinavica, 113(Suppl. 429), 51-59. doi: 10.111/j.1600-0447.2005.00718.x Lidz, C.W., Mulvey, E.P., Arnold, R.P., Bennett, N.S., & Kirsch, B.L. (1993). Coercive interactions in a psychiatric emergency room. Behavioral Sciences and the Law, 11(3), 269-280. Link, B.G., & Phelan, J.C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363-385. doi: 0360-0572/01/0811-0363$14.00


ACCEPTED MANUSCRIPT Neuendorf, K.A. (2001). The content analysis guidebook. Thousand Oaks, CA: Sage Publications. Nordt, C., Rössler, W., & Lauber, C. (2006). Attitudes of mental health professionals toward people with schizophrenia and major depression. Schizophrenia Bulletin, 32(4), 709-714. doi: 10.1093/schbul/sbj065


Ockwell, C. & Capital Member. (2007). Restraint: A necessary evil? In M. Hardcastle, D. Kennard, S. Grandison, & L. Fagin (Eds.), Experiences of mental health in-patient care: Narratives from service users, carers, and professionals (pp.48-55). New York, NY: Routledge. Overton, S.L., & Medina, S.L. (2008). The stigma of mental illness. Journal of Counseling & Development, 86, 143-151. Penn, D.L., & Martin, J. (1998). The stigma of severe mental illness: Some potential solutions for a recalcitrant problem. Psychiatric Quarterly, 69(3), 235-247. doi: 10.1023/A:1022153327316 Rogers, A. (1993). Coercion and “voluntary” admission: An examination of psychiatric patient views. Behavioral Sciences and the Law, 11, 259-267. Ruether, R.R. (2010). Many forms of madness: A family's struggle with mental illness and the mental health system. Minneapolis, MN: Fortress Press. Rüsch, N., Angermeyer, M.C., & Corrigan, P.W. (2005). Mental illness stigma: Concepts, consequences, and initiative to reduce stigma. European Psychiatry, 20, 529-539.


ACCEPTED MANUSCRIPT Scambler, G. (2009). Health-related stigma. Sociology of Health & Illness, 31(3), 441-455. doi: 10.1111/j.1467-9566.2009.01161.x Schiller, L., & Bennett, A. (1994). The quiet room: A journey out of the torment of madness. New York, NY: Warner Books. Schulze, B. (2007). Stigma and mental health professionals: A review of the evidence on an


intricate

relationship.

International

Review

of

Psychiatry,

19(2),

137-155.

doi:

10.1080/09540260701278929 Shearsmith-Farthing, K. (2009). Community mental 'elf'. Chipmunkapublishing. Short, N. (2007). Feeling misunderstood. In M. Hardcastle, D. Kennard, S. Grandison, & L. Fagin (Eds.), Experiences of mental health in-patient care: Narratives from service users, carers, and professionals (pp. 23-32). New York, NY: Routledge. Silverman, H.I. (2009). Qualitative analysis in financial studies: Employing ethnographic content analysis. Journal of Business & Economic Research, 7(5), 133-136. Smith, T.E., Sells, S.P., & Clevenger, T. (1994). Ethnographic content analysis of couple and therapist perceptions in a reflecting team setting. Journal of Marital and Family Therapy, 20(3), 267-286. doi: 10.1111/j.1752-0606.1994.tb00115.x Varley. J. (2007). Frustrated and angry. In M. Hardcastle, D. Kennard, S. Grandison, & L. Fagin (Eds.), Experiences of mental health in-patient care: Narratives from service users, carers, and professionals (pp. 95-102). New York, NY: Routledge.


ACCEPTED MANUSCRIPT Wahl, O.F (1999). Mental health consumers’ experience of stigma. Schizophrenia Bulletin, 25(3), 467-478. Weiner, B., Perry, R.P., & Magnusson, J. (1988). An attributional analysis of reactions to


stigmas. Journal of Personality and Social Psychology, 55(5), 738-748.


ACCEPTED MANUSCRIPT Table 1 Sample of client and family authored literature used in the present investigation. Book title

Author(s)/editor(s)

Date of

Brief description

publication


Experiences Mental

of

Health

Hardcastle,

2007

Kennard,

are on the front lines of mental

In-Patient Care: Grandison, & Fagin Narratives from Service

Users,

Carers,

and

Narratives authored by people who

health service provision: those

(Eds.)

seeking the services, their families, and providers. includes

Each chapter

commentaries

that

suggest lessons that might be

Professionals

learned from the narratives to improve services.

The Quiet Room:

Schiller & Bennett

1994

First

person-account

of

the

A Journey Out of

experience of schizophrenia, as

the Torment of

well as mental health service

Madness

receipt, with commentary from family and providers.


ACCEPTED MANUSCRIPT

Many Forms of Madness:

Ruether

2010

struggle with illness and treatment,

A

but also a discussion and criticism

Family’s Struggle


Mental

Not only a memoir of a family’s

with

of the mental health care system in

Illness

the United States, historic and contemporary.

and the Mental Health System

Billy:

One

Hawthorne

2009

Authored by the father of a young

Family’s

man living with mental illness, this

Journey Through

narrative is an account of their

the

treatment

Mental

Virginia

difficulties,

incongruence

Health

obstacles

System

involvement

in

to in

care, the mental

and

family’s health

services.

Fountain House: Portraits

Flannery &

1996

The narratives include those living with mental illness and staff

of


ACCEPTED MANUSCRIPT Lives Reclaimed from

Glickman

members of the Fountain House, a clubhouse that is member and

Mental

professional-partner in function, a

Illness

highly

successful

model

of

psycho-social rehabilitation. The narratives focused on exploring


the experience of mental illness and identification of models of treatment and coping that have enabled

the

client

to

more

successfully cope with mental illness.

My

Punished

Boyle

2004

Autobiographical,

self-published

Mind: A Memoir

depiction of his experience with

of Psychosis

mental illness, psychosis, and recovery

Community

Shearsmith-

2009

A scathing documentation of one woman’s

experience

with

in-


ACCEPTED MANUSCRIPT Mental ‘Elf’

Farthing

patient mental health services in


the United Kingdom.


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