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Stigma in Employment for Mental Health Patients

Employment is one of the major determinants of mental health and socially integration force. Exclusion from the employment sector brings about material deprivation, and erodes self confidence creating a sense of isolation and marginalization, and is an important risk factor for mental disability. This essay discusses recent evidence concerning employment-related discrimination and stigma faced by mental health patients. A wide understanding of the stigmatization process is adopted, and this includes attitudinal, structural, cognitive and behavioral disadvantages.

Stigma is both a distal and proximate cause of inequity in employment for people with mental disorder who experience direct discrimination due to prejudicial attitudes from workmates and employers and indirect discrimination from structural disincentives against competitive employment, historical patterns of disadvantage and generalized policy neglect. To fight this, mental health rehabilitation centers have been set up and legislative philosophies, which focus on the rights of citizens and full social participation. Recent findings indicate that the legislation remains vulnerable to the same prejudicial attitudes that they are intended to abate.

Researches that have been carried out in the recent past continue to highlight multiple structural and altitudinal barriers that prevent mentally challenged people from becoming active in the competitive labor markets. In Canada there is legislation on workplace disability which stipulates that employers should make ‘reasonable’ accommodations to be able to accommodate employees with mental disorder. An Example to this is when an employer decides to choose a more flexible work schedule for such a person. This is often not easy to achieve due to work related stereotypes.

Nearly nine out of ten people (87%) with mental health issues have been affected by stigma and discrimination (d, 2004). People with serious mental health problems have a relatively low employment rate as compared to any other disabled group but still they have a greater likelihood compared to any other disabled group to desire to be employment. Up to 90% of people with mental health problems confess that they would like to have a job. This is a greater percentage compared to the 52% of disabled people generally less than four in every ten employees (d, 2004)

There is a strong evidence that people with disability mental problems have reportedly being turned down in the job sector due to their mental health problem (work, 2002) or they give up on searching for employment because they anticipate discrimination (Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M, 2009). Almost three in every five employees (59%) have also confessed that they would not be comfortable talking to their manager about their mental health problems, if by any chance they had one (Poll, 2010). Disclosure in the place of work could also result in discriminatory from colleagues and manager like, lack of opportunities in advancement, gossip, micro-management, social exclusion and over inferring of mistakes to illness.

Stigma is conceptualized of compromising of three problems which are lack of knowledge (misinformation or ignorance); behavior (discrimination) and attitudes (prejudice) (Broham E, 2010). This framework has been recently used to carry out a survey of the employers based on attitudes, workplace behaviors and knowledge. Five hundred and two (502) employers were interviewed and several concerns were reported on hiring applicants with mental disability like work performance concerns mainly impaired job performance (20%), symptom concerns like a threat to their safety from the rest of the employees, (17%), they would not be capable of handling stress (14%), personality concerns such as negative treatment and attitude of other employees (2%) and they would require a higher level of monitoring (7%)

A study carried out by  Manning and White shows that previous work standards (89%), sick off times in the previous year (68%) whether receiving treatment (69%) and diagnosis (64%) are factors that are always or most of the times considered in decisions on hiring (Manning C, 1995) Fenton and his colleagues also discovered that sickness record (69%), diagnosis (36%), employment record (78%), medical opinion on the fitness to work (7%) and detention under the Mental Health Act (36%) were mostly reported as influential factors (Fenton Jw, 2003).

Krupa came up with four assumptions that bring about work place stigma. This were: People who have problems with their mental health are not competent enough to meet work demand , they are unpredictable and at times dangerous in the workplace, working is unhealthy for people with mental health issues and providing employment opportunities for such people is an act of charity. The above assumptions vary in their intensity and salience based on societal, individual and a range of organizational factors. The literature on factors that contribute to hiring decisions should be in such a way that, organizations comply with the Disability Discrimination Act when Supporting, and also hiring employees.

Depression and anxiety are common and part of the human condition. Up to one in four of us experience significant levels of mental distress every year. However, despite rising levels of sickness, absence, and incapacity benefit claims attributed to mental ill-health, the prevalence of common mental health problems in the workforce, and the general population has remained fairly stable over the past 20 years. Thus without being alarmist that there is a continuing and costly problem which employers find difficult to manage. What can occupational health professionals do to help?

First, occupational health professionals are in a uniquely authoritative position to explain what common mental health problems are, and what they are not. To do so, they will need to put their medical expertise into perspective. Perhaps a good starting point would be to show the terms ‘mild’ or ‘moderate’ when describing significant levels of mental distress. No one who is sufficiently distressed to seek medical help would describe themselves as having a mild depression. Henceforth, we should use the term common mental health problem which makes no presumptions about their severity or potential for becoming disabling. Occupational health professionals can also explain that common mental health problems are not a life sentence, they are amenable to treatment and that most people recover and return to work after a comparatively short while. There is of course need to be alert to the issue of ‘presenteeism’, when people insist on remaining at work until the situation has become so intolerable that it is hard to retrieve, but good communications between occupational professionals and line managers can often pick this up.

Most important of all the that occupational health professional is in the best position to explain that although medication is effective in managing crises and taking the edge off mood swings, mental ill-health leading to the long-term absence from work or risk of job loss is not solely or even mainly a medical issue. Once the absence has reached four to six weeks, alarm bells should be ringing that the person is not recovering as expected. The question the employer and the occupational health professional should therefore be asking is: what are the barriers to recovery and return to work that this person is experiencing?

It is necessary to make no assumptions at this stage. It may be that the distress has been triggered directly by a situation in the workplace that must be remedied, for instance bullying or being in the wrong job. However, it is safest to assume that barriers to recovery are multiple and individual to the person concerned and located within their entire network of relationships. It follows therefore that the remedy will be found within the individual and his/her relationships. The focus of the rest of this editorial will be on how occupational health professionals can help the individual and the employer manage deteriorating relationships in the workplace and restore trust and confidence.

The emphasis on relationship problems is vividly expressed in interviews with users of a job retention case management service in Bristol. The initial distress becomes the trigger for a vicious circle of depression, anxiety, despair, loss of mastery and loss of self-confidence. This is often reinforced by the breakdown in key relationships including but not exclusively those at work. The longer the process of disintegration goes on the harder it is to retrieve the situation.

The first key point for intervention is therefore the point when it the person discovers that he/she is not recovering as expected and doubts have started to creep into relationships with colleagues, managers and the company. We have already indicated that this point can be reached in as little as 4-6 weeks. It is possible to screen for risk of long-term absence, but most employers will have to rely on informal assessment. The important thing at this stage is to ensure that the employer keeps in touch on regularly and at least once in every 2 weeks. Occupational health professionals can facilitate this process and offer guidance on what to say.

It is necessary to ensure that everyone involved is working together especially the treating physician (usually the general physician), the line manager and the human resource department. Working together in this case means, giving out the same messages of reassurance and expectation of recovery. This requires an element of case management. Occupational physicians and especially occupational therapists are often at least partially prepared by their training to fulfill this role. For many people, a phased return will be necessary and it is often helpful if this is supported by medical authority. It is especially helpful to have a clinician available to talk to the treating physician and to negotiate a joint approach.

However, simply keeping in touch with the individual and waiting for the treatment to work may prolong absence unnecessarily. Indeed, there is some evidence that raising general public awareness of untreated depression can actually reduce labour market participation. Once a person has accepted the patient role, they may need help in refocusing their thoughts on becoming active, coping with the way they were before the bout of depression. There is strong evidence that a short course up to eight sessions of cognitive behavioral therapy can help enhance confidence and coping skills and reduce negative thinking 

However, cognitive behavioral therapy is not a magic bullet. It is not suitable for everyone or for all types of employment situation. It will not work if the workplace situation and relationships remain toxic. It will not help someone if they are in the wrong job. It seems to be more effective for people in high control occupations. A recent study of workplace interventions for people with mental health problem found good evidence in favor of cognitive behavioral therapy but also limitations in the evidence base which suggest that, attention should be given to developing, and evaluating a range of prevention strategies and cognitive educational tools which enable the interventions to be matched with the particular needs of the individual and the job.

What can occupational health professionals do to prepare themselves for managing these issues more successfully? Not everyone can or wants to become a cognitive behavioral therapist, but everyone can learn the principles of case management and everyone can learn simple techniques for talking confidently and therapeutically to people suffering depression or anxiety. Usefully the same principles apply to more serious mental health problems; the barriers are much the same, it is just that the stigma is greater. Motivational interviewing and solution-focused approaches have been found to be very helpful and can be safely be learned by everyone who has contact with people who need to change self-defeating thoughts and behavior.

The most important thing of all is to learn (and to help others to learn) how to normalize mental distress. This may sound paradoxical normalizing (the abnormal) but top of the list of barriers for returning to work by people with mental ill-health, is fear of stigma and discrimination which is unfortunately often well justified. To overcome this, it is necessary for those who know about the nature of mental ill-health to be able to speak about it as something which is known, normal and manageable. Health professionals sometimes tend to reify and pathologise mental distress and to shy away from dealing with the mess of strained or broken relationships it leaves in its wake. We must all now learn to use clinical skills, knowledge and authority to demystify common mental health problem and engage with those who experience it in ways that reduce fear and stigma, and help them rebuild their relationships and their lives.

The Disability Rights Commission should give priority to addressing discrimination in relation to people with mental health problems. The Government needs to recognize the importance of employment for people with mental health problems and implement initiatives that promote, support and, where necessary, provide opportunities for returning to employment. The benefits system should be re-examined in order that it does not penalize those who return to work but find that they are not well enough and have to leave. Employers should audit their workplace in order to identify elements of practice or culture that may be detrimental to mental health and seek to address these. Employers should consider policies such as a gradual return to work after a period of mental illness in order to support and retain valued employees. Employers should consider giving time off work for counseling/psychotherapy appointments as they would for other medical appointments. Medical professionals should seriously consider service users’ views and experiences when prescribing medications and seek a collaborative agreement to prescribe the most effective medication with fewer or more acceptable side effects. There should be mental health awareness training in schools to try and ensure that future employers and colleagues, for example, have a better understanding both of mental health problems and of how to take care of their own mental wellbeing.

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