Abstract
Objective:
Preliminary research suggests that mental health clinicians who work with people with severe mental illness may experience associative stigma, and the Clinician Associative Stigma Scale (CASS; Yanos et al., 2017) was recently developed and tested in a cross-sectional, online sample to examine this construct. The purpose of the present study was to further investigate the CASS’s psychometric properties, examining associations with measures of burnout, job satisfaction and “turnover intention” with service providers in a setting directly working with people with severe mental illness (i.e., a community mental health center). Furthermore, we examined these associations over a 6-month period to assess predictive validity of the measure.
Methods:
Participants were 68 providers working in a large community mental health center in a Midwestern city. Participants completed the CASS as well as measures of burnout, job satisfaction and turnover intention at two points in time (baseline and 6 months later).
Results:
The CASS significantly predicted burnout (emotional exhaustion and personal accomplishment) and job satisfaction when examined cross-sectionally, even after controlling for demographic characteristics. Longitudinal analyses showed that increased associative stigma was associated with increased burnout and lower job satisfaction over time.
Conclusions and Implications for Practice:
Associative stigma may have negative consequences for mental health service providers, as well as the consumers they serve, and the CASS appears to be a useful tool to study this phenomenon. Associative stigma may be an appropriate target for interventions designed to reduce burnout among mental health providers.
Introduction
The construct of “associative stigma” was introduced by Goffman (1963), who asserted that it is not unusual for persons who are “related through the social structure to a stigmatized individual” to “share some of the discredit of the stigmatized person to whom they are related” (p. 30). Given extensive evidence of stigma toward people diagnosed with severe mental illnesses (Yanos, 2018), it is not surprising that associative stigma is also a concern. A considerable body of research has confirmed that family members of such individuals experience a variety of forms of associative stigma, including demeaning social interactions with community members (e.g., negative comments), diminished status, and social avoidance by community members (e.g., Angermeyer et al., 2003; Krupchanka et al., 2016; Mak & Cheung, 2008; Struening et al., 2001).
In addition to family members, research suggests that professionals who work with discredited groups may also experience associative stigma (e.g., service providers with sex workers and people with HIV/AIDS [Phillips, Benoit, Hallgrimsdottir, & Vallance, 2012; Snyder, Omoto, & Crain, 1999]). Mental health service providers who routinely interact with persons with severe mental illness might also be affected by associative stigma. An international survey on the stigmatization of psychiatry in 12 different countries indicated that psychiatrists perceive a moderate degree of stigma toward their profession (including diminished status), and greater stigma in comparison to general practitioners (Gaebel et al., 2015). Another study used both qualitative and quantitative methods with members of the general public to explore stigma toward both mental health professionals and general practitioners, and found greater endorsement of negative stereotypes toward mental health professionals than general practitioners (Ebsworth & Foster, 2017). A large study in Belgium found that a range of mental health clinicians commonly endorsed negative reactions and hearing jokes from members of the general public about their professions (Verhaege & Bracke, 2012). This study also found a significant association between endorsement of associative stigma experiences and both emotional exhaustion (a component of “burnout”) and diminished job satisfaction among practitioners. Furthermore, people diagnosed with mental illnesses who received services from professionals that endorsed more associative stigma experiences endorsed more self-stigma. This raises the possibility that emotional responses (such as burnout) to associative stigma may impact people diagnosed with mental illnesses, who may be more likely to perceive that their disorders are shameful and develop self-stigma.
Burnout remains a relevant issue for health professionals and their clients, and recent reviews have found that over 50% of psychotherapists report moderate to high levels of burnout (Simionato & Simpson, 2018), and that it is associated with unsafe care, unprofessional behaviors, and low client satisfaction (Panagioti, Geraghty, & Johnson, 2018; Salyers et al., 2017). In addition, burnout is associated with lower job satisfaction and higher likelihood of turnover (Mor Barak, Nissly, & Levin, 2001). Professional behaviors related to burnout are likely to be antithetical to an environment of recovery-oriented care and negatively impact client outcomes. Thus, a better understanding of the predictors of burnout and how best to manage burnout when it is occurs is crucial for providing high quality care.
In an effort to facilitate a more systematic understanding of the effects of associative stigma among mental health clinicians, Yanos, Vayshenker, DeLuca and O’Connor (2017) developed the Clinician Associative Stigma Scale (CASS) based upon the themes expressed by clinicians in a prior qualitative study (Vayshenker et al., 2018). This scale aimed to be the first validated scale of associative stigma among mental health professionals, since Verhaege and Bracke’s prior (2012) study had only used a 4-item index. A validation study with 472 mental health clinicians in the United States found that associative stigma experiences were commonly endorsed (with 8 items endorsed as being experienced at least “sometimes” by a majority of participants). The CASS also demonstrated good internal consistency and a logical, four factor structure (“Negative Stereotypes about Professional Effectiveness,” “Discomfort with Disclosure,” “Negative Stereotypes about People with Mental Illness,” and “Stereotypes about Professionals’ Mental Health”), and was significantly related to measures of burnout and quality of care. More recently, Lin et al. (in press) administered a translated version of the CASS to 665 psychiatrists and psychiatric nurses working in inpatient settings within China. This study confirmed the internal consistency and factor structure of the CASS, although associative stigma scores were lower overall among the Chinese clinicians.
Although the research conducted to date suggests that the CASS is a reliable and valid measure, a limitation of Yanos et al.’s (2017) study was that participants were recruited online through professional societies, which may have attracted participants because of their interest in the topic of associative stigma. Confirmation that clinicians worked with people with serious mental illness was also based on self-report, and it is therefore possible that some participants did not actually work with such individuals. Further, Yanos et al.’s sample lacked diversity, with only 4% of participants identifying as African-American, suggesting the need for research with more diverse groups of service providers. Validation in a diverse sample of clinicians serving people with severe mental illness is therefore needed.
The purpose of the present study was to further investigate the psychometric properties and utility of the CASS by examining its association with measures of burnout, job satisfaction and “turnover intention” (or intent to leave one’s job) with a group of clinicians at a specific setting where people with severe mental illness are routinely served (i.e., a community mental health center). Furthermore, the association between CASS scores and these measures was examined at two points in time (baseline and 6 months later). It was hypothesized that the CASS would continue to demonstrate good psychometric properties, would be stable over time, and would be associated with increased burnout and turnover intention, and negatively associated with job satisfaction.
Methods
Design Overview
Data were drawn from a larger study focused on developing an organizational approach to reducing burnout among mental health practitioners. The research received approval from the Institutional Review Board of the third author’s institution.
Setting, Participants, and Procedures
Participants were employees of a large community mental health center in a Midwestern city. Study participants included treatment providers (e.g., case managers, psychiatrists, therapists), support staff (e.g., receptionists), and managers of one of the specified teams serving persons with severe mental illness: 3 assertive community treatment (ACT) teams (initially 40 staff) and 4 outpatient adult treatment teams (initially 56 staff). Recruitment consisted of research staff briefly presenting study information during team meetings and answering questions, followed by email invitations. Surveys were conducted every 6 months throughout the study for all teams. Current analyses are based on data from two study waves, in which 68 participated at time 1 (note that demographic data were only available for 67 participants), and 53 of those participants completed measures at time 2. Survey participants received a $10 gift card for each survey completed.
Characteristics of participants at baseline are provided in Table 1. As can be seen in Table 1, participants were predominantly female, white, with a bachelor’s degree, in their late 30’s, and had been working in the mental health field for roughly 10 years. Although participants were predominantly white, a significant minority (nearly 30%) identified as African- American or multi-racial.
Table 1:
Demographic and Work-Related Characteristics of Participants (n = 68)
| N | % | |
|---|---|---|
| Education: | ||
| Associates Degree | 4 | 5.2 |
| Bachelor’s degree | 31 | 40.3 |
| Master’s degree | 21 | 27.3 |
| Ph.D/Psy.D | 4 | 5.2 |
| Other | 8 | 10.4 |
| Gender: | ||
| Female | 53 | 77.9 |
| Male | 15 | 22.1 |
| Race/Ethnicity: | ||
| African-American | 15 | 22.1 |
| White | 47 | 69.0 |
| All Other/Multiracial | 5 | 7.3 |
| Field of Degree/Education: | ||
| Business Administration | 2 | 2.6 |
| Nursing | 9 | 11.7 |
| Psychiatry | 1 | 1.3 |
| Psychology | 18 | 23.4 |
| Public Health | 1 | 1.3 |
| Social Work | 21 | 27.3 |
| Other | 16 | 20.8 |
| N | Mean (SD) | |
| Age | 67 | 38.6 (14.7) |
| % of time dedicated to direct service | 60 | 23.4 (8) |
| Total number of years in the mental health field | 67 | 10.5 (12.3) |
Measures
Survey Measures.
We collected background characteristics, including demographics, type of degree, primary discipline and role on the team, length of time in the mental health field and length of time in their current position, caseload size, average hours worked per week, and if responsible for supervising other employees. The remainder of the survey focused on the social context of work, stressors/demands, resources, and outcomes.
Associative Stigma.
We assessed associative stigma using the Clinician Associative Stigma Scale (CASS; Yanos et al., 2017). The CASS is an 18-item scale which asks participants to think specifically about their work with adults with serious mental illnesses (including diagnoses such as schizophrenia and bipolar disorder) and to report the frequency of experiences: 1 = never, 2 = rarely (only occurred once or twice), 3 = sometimes (repeatedly, but irregularly), and 4 = often (occurs regularly). Higher scores reflect higher levels of associative stigma. Previous research with the CASS identified four factors: “Negative Stereotypes about Professional Effectiveness” (e.g., “I have heard people state or joke that work with people with serious mental illness is a job that doesn’t require much skill”; 6 items), “Discomfort with Disclosure” (e.g., “When I have met a new person at a social gathering, I am reluctant to discuss my work with people with serious mental illness”; 4 items), “Negative Stereotypes about People with Mental Illness” (e.g., “When I tell them about the work that I do, people outside of the mental health field express concern for my safety related to my work with people with serious mental illness”; 4 items), and “Stereotypes about Professionals’ Mental Health,” (e.g., “In media depictions that I have encountered, mental health professionals are depicted as having personal psychological problems”; 4 items). Internal consistency for the CASS was good in the present study and similar to what had been previously found (alpha = .88).
Outcomes.
Burnout was assessed with the twenty-two item Maslach Burnout Inventory (Maslach, Jackson, & Leiter, 1996), a widely-used measure of emotional exhaustion, depersonalization, and personal accomplishment. The subscales have shown good internal consistency, stability over time, and convergent validity with related constructs. Job Satisfaction was measured using two questions: “On the whole, how satisfied are you with the work you do?” and “On the whole, how satisfied are you with this job?” (rated from 1 = “very dissatisfied” to 5 =”very satisfied”). Turnover Intentions are consistently some of the best predictors of turnover (Tett & Meyer, 1993), and are considered important to employers in themselves (e.g., one might intervene when intention is high, compared to after an employee has left) (Salyers et al., 2014). We assessed intentions with two individual items: “How often have you seriously considered leaving your job in the past six months?” (rated from 1=”never” to 6=”several times a week”) and “How likely are you to leave your job in the next six months?” (rated from 1=”not likely at all” to 4=”very likely”). We refer to these as turnover consideration and turnover plan, respectively.
Results
Test-Retest Validity.
We began by examining mean scores for the CASS and their stability over time. At baseline, the mean CASS score was 2.16 (SD = .5), which was approximately 4/10th of a SD lower than what was found in the previous (Yanos et al., 2017) validation study (with a mean of 2.35). Regarding the stability of CASS scores, we found a correlation of r = .65 between CASS scores at time 1 and time 2 (six months later), suggesting that scores are moderately stable.
Demographic Correlates of CASS.
We next examined demographic predictors of CASS score. We found that CASS scores were not significantly associated with age, gender, or education. However, CASS score was significantly associated with race, with participants identifying as African-American or multiracial scoring approximately a full standard deviation higher than participants identifying as white (mean = 2.55 [SD = .59] vs. 2.04 [SD = .28], p < .01), indicating that African-American and multiracial participants were more likely to report associative stigma.
Correlation with Outcomes at Baseline.
We next examined correlations between CASS and measures of Burnout, Job Satisfaction and Turnover Intention at baseline. As can be seen in Table 2, and consistent with what was hypothesized, CASS scores at baseline were correlated significantly (and in expected directions) with 2 of 3 Maslach Burnout Inventory subscales: emotional exhaustion (r=.27, n=63, p=.03) and personal accomplishment (r=−.32, n=64, p=.01). There was a trending relationship in the expected direction between CASS and the third aspect of burnout, depersonalization (r=.23, n=64, p=.07). CASS was also correlated significantly with Job Satisfaction (r=−.26, n=64, p=.04), but, contrary to what was hypothesized, not with either aspect of turnover intention (either consideration or plan). Of note, emotional exhaustion, depersonalization and job satisfaction were significantly moderately associated with turnover consideration, but only job satisfaction was significantly associated with turnover plan.
Table 2:
Correlation Between Associative Stigma and Outcome Variables at Time 1 (N = 64)
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | |
|---|---|---|---|---|---|---|---|
| 1. Clinician Associated Stigma Scale (CASS) | --- | ||||||
| 2. Maslach Burnout Inventory (MBI) - Emotional Exhaustion | .27* | --- | |||||
| 3. Maslach Burnout Inventory (MBI) - Depersonalization | .23 | .71** | --- | ||||
| 4. Maslach Burnout Inventory (MBI) - Personal Accomplishment | −.32** | −.18 | −.31* | --- | |||
| 5. Job Satisfaction | −2.6* | −.50** | −.39** | .31* | --- | ||
| 6. Turnover Consideration | −.06 | .32** | .28* | −.18 | −.29* | --- | |
| 7. Turnover Plan | −.02 | .25 | .20 | −.14 | −.48** | .18 | --- |
Correlation is significant at the 0.05 level (2-tailed)
Correlation is significant at the 0.01 level (2-tailed)
We next used regression to examine whether CASS would significantly predict emotional exhaustion, personal accomplishment and job satisfaction controlling for age, education, race and gender, which are demographic characteristics that sometimes predict burnout (see Table 3). Consistent with what was hypothesized, CASS was significantly associated with emotional exhaustion and job satisfaction outcomes when controlling for these predictors and was borderline significantly associated with personal accomplishment. In each equation, the inclusion of CASS in the equation increased R-squared explained by approximately 10%. Of note, greater age was also a significant predictor of personal accomplishment, but otherwise demographic characteristics did not significantly predict emotional exhaustion, personal accomplishment and job satisfaction when CASS was included in the models.
Table 3.
Hierarchical Linear Regressions of Emotional Exhaustion, and Job-Related Variables on Demographic Characteristics and Associative Stigma
| Emotional Exhaustion | ||
|---|---|---|
| β | R2 Δ | |
| Step 1 (Background Demographics) | 0.10 | |
| Age | −.12 | |
| Race (0=white, 1= African-American or multiracial) | −.12 | |
| Gender (0= male, 1= female) | −.19 | |
| Education | −.10 | |
| Step 2 (Associative Stigma) | 0.20* | |
| Age | −.14 | |
| Race | −.20 | |
| Gender | −.17 | |
| Education | .11 | |
| CASS | .37* | |
| Personal Accomplishment | ||
| β | R2 Δ | |
| Step 1 (Background Demographics) | 0.21* | |
| Age | .34* | |
| Race (0=white, 1= African-American or multiracial) | −.24* | |
| Gender (0= male, 1= female) | −.09 | |
| Education | −.15 | |
| Step 2 (Associative Stigma) | 0.29* | |
| Age | .33* | |
| Race | −.19 | |
| Gender | −.08 | |
| Education | .13 | |
| CASS | −.25§ | |
| Job Satisfaction | ||
| β | R2 Δ | |
| Step 1 (Background Demographics) | 0.02 | |
| Age | .11 | |
| Race (0=white, 1= African-American or multiracial) | −.05 | |
| Gender | .05 | |
| Education | .05 | |
| Step 2 (Associative Stigma) | 0.12 | |
| Age | .13 | |
| Race | .04 | |
| Gender | .02 | |
| Education | .02 | |
| CASS | −.32* | |
p<0.05,
p = 0.05
Change Over Time.
Finally, we examined the correlation between change in CASS score between baseline and 6-month follow-up and change in the other outcome variables for the 53 participants who completed both waves, after creating change scores for all variables by subtracting time 1 values from time 2 values (see Table 4). Change over time in CASS was significantly and moderately associated with change in the emotional exhaustion subscale of the MBI, such that increases in CASS were associated with increases in emotional exhaustion. There was also a borderline significant negative association between increase in CASS and decrease in job satisfaction. There was no association between change in CASS and either turnover consideration or turnover plan. Of note, increases in emotional exhaustion and decreases in job satisfaction were both significantly associated with increases in both dimensions of turnover intention.
Table 4:
Correlation Between Change in Associative Stigma and Change in Outcome Variables (N = 53)
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | |
|---|---|---|---|---|---|---|---|
| 1. Increase in CASS | --- | ||||||
| 2. Increase in MBI - Emotional Exhaustion | .39** | --- | |||||
| 3. Increase in MBI - Depersonalization | .17 | .36** | --- | ||||
| 4. Increased in MBI - Personal Accomplishment | .06 | −.10 | −.05 | --- | |||
| 5.Increase in Job Satisfaction | −28§ | −.48** | −.24 | .24 | --- | ||
| 6. Increase in Turnover Consideration | .16 | .45** | −.25 | −.10 | −.36** | --- | |
| 7. Increase in Turnover Plan | .09 | .42** | .30* | −.26 | −.37** | .45** | --- |
Correlation is significant at the 0.05 level (2-tailed)
Correlation is significant at the 0.01 level (2-tailed)
p = 0.05
Discussion
Findings from the current study replicate and extend previous findings regarding the utility of the CASS to assess associative stigma among mental health clinicians, extending research to a group of clinicians with documented involvement with persons with severe mental illnesses at two points in time. Consistent with hypotheses, the CASS demonstrated good internal consistency, was demonstrated to be relatively stable over time, and was found to be associated with increased burnout and negatively associated with job satisfaction. The hypothesis regarding turnover intention was not supported, however.
The CASS was a significant predictor of burnout (emotional exhaustion and personal accomplishment), as well as job satisfaction when examined cross-sectionally, even when controlling for demographic characteristics. Findings with regard to personal accomplishment are new, as the Oldenburg Burnout Inventory (used previously by Yanos et al., 2017) does not contain this subscale. The personal accomplishment subscale of the MBI measures feelings of “competence and successful achievement”; the significant correlation between personal accomplishment and associative stigma might be related to a belief that clinicians who work with people with severe mental illness lack “status” in their mental health careers. Findings demonstrating that the CASS was significantly associated with job satisfaction are also an important contribution as they were not explored in the previous study. Thus, associative stigma may be an important factor in the occupational well-being of mental health providers.
The finding that CASS scores were significantly higher among African-Americans is a new and potentially important finding. Given that the prevalence of negative stereotypes about serious mental illness has been found to be greater in the African-American community than among whites (see, for example, Anglin et al., 2006), it is plausible that African-American clinicians experience heightened associative stigma within their communities. It is also plausible that African-Americans may be more attuned to concepts of stigma, given personal experiences with racism and discrimination (Rao, Feinglass, & Corrigan, 2007). From a perspective of intersectionality (Crenshaw, 1989), it may also be that African-American providers perceive their professional identity as another potential aspect of their identity that needs to be “managed,” perhaps serving as a “double stigma” (Erevelles & Minear, 2010). Such experiences of compounded stigmas have been documented among individuals living with serious mental illness (West et al., 2018), and future research should further examine this process among mental health professionals.
Findings regarding the association between increased CASS over time and changes in emotional exhaustion and job satisfaction are also notable. Although we cannot infer causality, our findings suggest that perceived associative stigma could contribute to increased burnout and lower job satisfaction over time and may therefore be an important target of intervention for mental health professionals. Although increases in CASS scores were not directly related to either dimension of turnover intention, both emotional exhaustion and job satisfaction were. It is possible that associative stigma might exert an “indirect effect” on these outcomes (see Hayes & Rockwood, 2017, for a discussion of indirect effects). However, the modest sample size of the current study and having only 2 time points of data limited our ability to examine such relationships. It is also plausible that the direction of the effect may be such that burnout causes mental health providers to have a more negative outlook regarding their work and perceive more associative stigma. Future research could examine the possible indirect impacts of associative stigma using a larger sample and disentangle the direction of the effect by including more time points.
Although this study took place in a relatively small sample in one setting, it extends prior work (Yanos et al., 2017; Lin et al., in press) establishing CASS as a useful tool to assess associative stigma among mental health providers. Given longstanding needs for enhancing provider well-being (Dreison et al., 2018), associative stigma is another potential avenue for intervention. Addressing associative stigma among providers may also impact client outcomes by decreasing burnout, which is antithetical to recovery-oriented care, as previously noted. Our findings also point to a number of directions for future research, for example in examining compound stigmas that minority mental health providers may face, and assessing potential pathways to turnover.
Impact and Implications.
Associative stigma is frequently experienced by providers working with people with serious mental illness and is associated with increased burnout and decreased job satisfaction. Associative stigma may be one mechanism by which providers’ empathy for persons with severe mental illness is eroded and should be targeted in intervention.
Acknowledgments
Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under Award Number R34MH104201 (Burnout Reduction for MH Providers to Improve QOC and Reduce Staff Turnover). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Contributor Information
Philip T. Yanos, John Jay College of Criminal Justice & The Graduate Center, CUNY
Joseph S. DeLuca, John Jay College of Criminal Justice & The Graduate Center, CUNY
Michelle P. Salyers, Indiana University-Purdue University Indianapolis
Melanie W. Fischer, Indiana University-Purdue University Indianapolis
Jennifer Song, John Jay College of Criminal Justice, CUNY.
Juliana Caro, John Jay College of Criminal Justice, CUNY.
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