A recent study published in Psychological Services explored how “prosumers” of psychological services – in this case, psychologists with lived experience of mental distress who used mental health services themselves – experienced mental health-related stigma.
Doctoral candidate Laura López-Aybar and other researchers from Adelphi University and Columbia University Irving Medical Center developed a mixed-methods study to better understand prosumers’ stigmatizing experiences. Through their qualitative analysis, they found prosumers witnessed discrimination, anticipated and internalized stigma, and sought to resist stigmatization within their field and their communities.
According to the authors:
“Clinical psychologists and mental health professionals, in general, are not exempt from holding stigmatizing views and attitudes. On average, mental health professionals are less likely than community members and other health care providers to discriminate and are more flexible in their attitudes. However, these professionals do still hold implicit biases and stereotyped views toward individuals with psychiatric labels.”
Stigma has been understood as a “disgraceful stamp” or a label assigned to people or groups that lead to prejudice. The field of public health has identified stigma as a social determinant of health; this label is accompanied by discriminatory institutional and interpersonal dynamics, which leaves the stigmatized vulnerable and marginalized.
Psychiatric stigma often leads those stigmatized to feel shame and hopelessness, have decreased self-worth, and have suicidal ideation. Different diagnoses are associated with varying degrees of stigmatization, as stigma is partially associated with fear and misunderstanding. This might explain the disparate stigma against people diagnosed with psychotic disorders, which increases their psychological distress.
While the biomedical model and other individualizing theories of mental health have served to reproduce psychiatric stigma, psychosocial models of mental health and understanding psychological distress as a continuum aid in reducing stigma.
Many clinical psychologists and trainees have stigmatizing attitudes toward people with psychiatric diagnoses, even though they are, on average, less likely to discriminate against them. This includes clinical psychology “prosumers,” who have lived experiences of mental distress and use mental health services. Prosumers often witness and anticipate stigma and discrimination due to their diagnoses, yet many are still drawn to clinical psychology training because of their experiences with psychological distress.
However, training programs often discriminate against these applicants. Some faculty evaluators even oppose the disclosure of psychiatric labels in graduate application materials. These acts of “gatekeeping” can prevent highly skilled and competent individuals from entering graduate psychology programs.
Even after training and becoming clinicians, prosumers continue to experience the effects of psychiatric stigma. They tend to hold less internalized stigma than mental health providers without a psychiatric diagnosis but also experience significantly higher levels of anticipated stigma. Prosumers with doctoral-level training experience even more anticipated stigma and general stigma than those with master’s-level training.
Despite not often internalizing stigmatizing attitudes, clinical psychology prosumers are more likely to anticipate discrimination against them. This anticipated stigma increases their psychological distress and hinders their relationships with colleagues, as they fear that stigma will negatively impact their professional development. In addition, they often experience discrimination from within their own field.
To explore and understand prosumers’ experiences of stigma and discrimination within clinical psychology, doctoral candidate Laura López-Aybar and colleagues developed a mixed-methods study. Participants included 136 doctoral clinical psychology students in training and 39 doctoral-level clinicians diagnosed with any psychiatric disorder in the DSM-V.
The study found that major depressive disorder and generalized anxiety disorder were the most common diagnoses reported among participants. López-Aybar and colleagues used an online survey including open-ended questions and quantitative measures of witnessed discrimination, microaggressions, internalized stigma, anticipated stigma, and stigma resistance. They used descriptive statistics alongside grounded theory qualitative methods to understand the stigmatizing experiences of prosumers.
Through the qualitative analysis, López-Aybar developed four core categories to describe and explain the participants’ experiences of stigma: witnessed discrimination, anticipated stigma, internalized stigma, and stigma resistance.
Most of the participants reported witnessing various forms of discrimination. For example, many prosumers observed invalidation of people with lived experiences, over pathologization, and providing catastrophic prognoses. They also experienced discrimination in the form of condescending attitudes, being punished by denying services or taking away their autonomy, and being the “butt of jokes” within training programs. Witnessing discrimination led to psychological distress and negative feelings toward the field of clinical psychology.
Many participants reported anticipating stigma, which included having their agency and identity rejected by others. They feared being seen as incompetent, retaliated against, and having their identities reduced to their diagnosis. Although some participants believed they would be accepted or celebrated by some peers, this was dependent on the perceived severity of their assigned diagnosis.
Some participants reported internalized stigma, leading to feelings of being unlikeable or not functional enough for their role. However, others believed that their diagnosis made them more empathic and competent. Prosumers believed that colleagues, physicians, family, friends, society and culture, and other personal experiences influenced the development of their internalized stigma.
Prosumers reported engaging in actions aimed at resisting or challenging psychiatric stigma. These actions included participation in professional or grassroots organizations, teaching, and engaging in scholarship to challenge stigma. They also engaged in community engagement by providing testimonies and challenging misinformation. While resistance was emotionally and professionally taxing, it offered a sense of empowerment, connection with others with similar experiences, and motivation to continue working as clinicians.
This study contributes to the expanding literature on the stigma against individuals with psychiatric diagnoses or lived experiences of mental illness. The findings indicate that despite some degree of acceptance within the field of clinical psychology, the ongoing stigma impacts both patients and clinicians with psychiatric diagnoses. Although clinicians with lived experiences may possess increased empathy and understanding, they experience heightened distress due to the stigmatizing work environments and dynamics they encounter.
Therefore, the field of clinical psychology, including its training programs and workspaces, must continue to evolve to create hospitable and humanizing spaces for patients and clinicians alike. Such changes would facilitate the reduction of stigma and promote the growth of a more inclusive, empathetic clinical psychology community.
López-Aybar, L., Gonzales, L., & Kanani, A. (2023). Prosumers’ experiences of stigma dimensions within the clinical psychology field. Psychological Services. Advanced online publication. https://doi.org/10.1037/ser0000765 (Link)