Introduction
The term recovery has been gaining traction in the mental health field in recent years, and has also become the guiding principle for mental health systems in many countries [
1,
2]. Recovery has been largely defined as “a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles” and “a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness” [
3,
4]. In recent years, recovery-oriented practices have shifted towards being more individual-focused and centred around helping people lead meaningful lives [
4]. However, there has yet to be a consensus on what the term means, as evinced by a review that suggested that there are differing views among persons with mental illnesses (PMI), caregivers, and service providers on what recovery entails [
5]. Likewise, the literature suggests that there are also differing opinions on the factors that impact the recovery of PMI [
6‐
8]. One of the most widely studied barriers to recovery is the stigma towards mental illness. Angermeyer and Schomerus [
9] argued that it is essential to understand stigma concurrently when investigating recovery, as stigma might account for some of the blind spots of recovery, for “where recovery sees challenges, stigma identifies obstacles”. There is compelling evidence in the literature evincing that stigma often affects the recovery of the service users [
10,
11]. For instance, stigma may discourage an individual from seeking help due to the fear of being labelled with a mental illness diagnosis [
12]. Even amongst individuals who have sought treatment, their recovery may also be compromised by self-stigma [
10,
13]. The pessimistic views that healthcare professionals hold towards recovery, also known as therapeutic pessimism, is another form of stigma experienced by those seeking help, which has been demonstrated to exert a pernicious effect on the consumer’s recovery [
11]. In mental health settings, therapeutic pessimism is defined as the inclination to believe that PMI are difficult to treat or immune to treatment [
14]. Perhaps more troubling is that research has established an association between pessimistic views of recovery and a sense of helplessness for some healthcare professionals, which leads them to believe that ‘‘what they do doesn’t matter’’ [
15], adding to the problem of inadequate treatment provision. Additionally, a corollary to stigma is the reduced opportunities available to consumers and greater social exclusion [
16]. Therefore, understanding stigma and its underlying reasons are pivotal in ensuring that interventions designed to reduce stigmatisation target specific underlying issues that serve as barriers to PMI’s recovery.
Stigma toward PMI is not the only factor that impacts recovery – stigma experienced by healthcare professionals working closely with PMI can also indirectly contribute as a barrier to PMI’s recovery. In recent years, there is a growing interest in associative stigma experienced by healthcare professionals in mental health settings, whereby these professionals are judged with similar stigmatising stereotypes as their patients [
17]. This was largely explored in a qualitative study by Vayshenker and colleagues, postulating that associative stigma experienced by these healthcare professionals can lead to severe consequences in the quality of care provided to PMI [
18]. To be more specific, the established link between emotional exhaustion, job dissatisfaction, and associative stigma might lead to diminished empathy towards PMI [
18]. For example, the study revealed that factors such as job devaluation (e.g., minimizing the training required for mental health professionals) contributes to feelings of frustration and burnout among these healthcare professionals [
3]. Other studies have also revealed that psychiatric nurses were deemed as less skilled and valued or even viewed as not “real” nurses [
19‐
21]. These stereotypes associated with mental health professionals not only devalues the role these individuals play in treatment and recovery but also underplay the needs of PMI in the healthcare system. In addition, these stereotypes can further aggravate stigmatising beliefs about mental health conditions [
15]. Other studies have similarly found that stigmatisation by association influences professional burnout, depersonalisation, lower job satisfaction, and emotional exhaustion among healthcare professionals working with PMI [
20,
22‐
24]. PMI also described higher self-stigma and decreased satisfaction in healthcare institutions when their healthcare professionals experience more associative stigma [
17]. Extensive literature has also exhibited the link between work stress and performance, indicating that stress in the workplace because of stigmatisation influences interpersonal performances, such as reduced sensitivity toward PMI and increased disregard of individual differences among PMI [
20]. Thus, they may be less likely to provide quality services to their clients, serving as a barrier to recovery [
18].
Despite the role of healthcare professionals in understanding mental health stigma and its impact on recovery, a look into current literature reveals a pattern of investigating stigma and recovery from the standpoint of service-users and the general public, with a scarcity of research done to address the perspectives of healthcare professionals working in mental health settings [
25,
26]. This is surprising in many respects, considering that PMI regularly interact with these healthcare professionals [
18]. There are certain advantages to understanding stigma and barriers to recovery through the perspectives of healthcare professionals. Firstly, as compared to consumers’ and caregivers’ perspectives, healthcare professionals may sometimes be able to provide more objective third-party insights, such as in contexts where palpable tensions exist between the consumer and the caregivers or when caregivers are overprotective [
27]. Secondly, although PMI are the most important individuals to discuss barriers and facilitators to recovery, they may sometimes also possess poor insight towards their mental illness such as a lack of awareness of their symptoms, significance, and severity of their illness, which may be associated with poorer perceptions of experienced stigma [
28‐
30]. Furthermore, a study by Happell and colleagues reported that consumers felt that their recovery was hindered when healthcare professionals prioritised treating them according to symptoms instead of their individual needs [
31]. Hence, understanding recovery and stigma from healthcare professionals’ perspectives may elucidate some insights as to whether it matches consumers’ expectations. Most importantly, healthcare professionals are often present in situations where they can witness significant breakthroughs and outcomes in patients which surpasses expectations [
27,
32]. For these reasons, it would be beneficial to consider healthcare professionals’ viewpoints on the barriers and facilitators to recovery.
According to Slade et al. [
4], it is important to investigate factors that enable or hinder recovery within a non-Western cultural context to develop more culturally relevant recovery concepts that can better address the needs of service users. To our knowledge, there are limited publications in the literature about the topic of recovery in Singapore [
33,
34], a country in Southeast Asia where the lifetime prevalence of mental illness is reported to be approximately 13.9% [
35]. Mental health services in Singapore are delivered both in hospitals and at the community level. The Institute of Mental Health (IMH) is the only state-run psychiatric hospital comprising in-patient and out-patient services. Public and private hospitals deliver inpatient and outpatient mental health services also but in small-scale capacities [
36]. In the community, mental health services are delivered by primary care physicians in state-run clinics (i.e., polyclinics) or as General Practitioners (GP), psychologists, and counsellors working in either volunteer welfare organisations that provide care to PMI or educational institutions and other settings [
36]. A nationwide survey reported considerable stigma towards PMI in Singapore among the general public [
35], and stigma has also been surmised to be a contributor to the wide treatment gap in Singapore. Treatment gap is defined as the absolute difference between the prevalence of a particular mental disorder and those who had received treatment for that disorder [
37]. Anationwide study revealed that more than three-quarters of individuals (78.6%) did not seek help despite meeting the criteria for a mental disorder [
37]. Qualitative evidence in Singapore also indicates that PMI do experience discrimination and prejudice due to stigma [
38]. Even though stigma possesses ubiquitous features across contexts, the specific experiences and manifestations of stigma may be localised and vary according to the cultural context [
39,
40]. To date, there has yet to be any qualitative study that explored both stigma and recovery in Singapore, specifically from the healthcare professionals’ (HP) perspective. This study aims to utilise a qualitative approach to investigate how stigma affects the recovery of PMI through the lens of HP working in mental health settings in Singapore. Since stigmatising processes operate on multiple levels, the study adopted Logie et al.’s concept of multilevel forms of stigma – micro (intra/interpersonal), meso (social networks/community/norms), and macro (structural/institutional exclusion/discrimination) to understand the determinants of stigma that affect recovery [
41].
Discussion
This study adopted a stigma perspective towards understanding recovery, and elucidated HP’s viewpoints on how the stigmatisation of mental illness affects the recovery for PMI, the findings of which were organised using a multilevel approach inspired by the earlier works of Logie et al., 2011 [
41]. These themes were categorised into different levels to better conceptualize a model that elucidates mental health stigma in our findings (see Fig.
1). While the outcomes of this study may not be completely unique, given that certain features of stigma are ubiquitous, there are some salient points worth discussing.
Our analysis indicates that stigma on a personal level can have quite a deleterious effect on the individual’s willingness to seek help or even acknowledge their illness in the first place. A systematic review of 14 studies sheds light on some of the effective features of interventions that reduce self-stigma, such as empowering PMI and improving their self-esteem, both of which are key components of recovery-oriented practice [
55,
56]. The findings of this study also observed the detrimental effect of cultural influences in Singapore on recovery. As elaborated by participants of this study, cultural influences associate mental illness with shame, which inhibits the help-seeking intentions of the consumer. This finding is consistent with a previous local study by Tan et al. [
44], which showed that cultural misgivings towards mental illness such as the Chinese concept of “face” [
57] contributes to the stigma of mental illness for it imparts shame to the sufferer and possibly their families as well [
39]. Additionally, analogous to the findings of the present paper, a qualitative study exploring the viewpoints of Chinese medical students in China also highlighted the concept of “loss of face” that was deeply integrated in the society’s treatment of both PMI and individuals associated with it [
58]. According to the study, this cultural factor is also reflected in the devaluation of the field of psychiatry, with Chinese medical students expressing that the field of psychiatry is often undervalued, and poorly taught and that psychiatric facilities are often underdeveloped [
58]. Cultural influences may also compound the recovery process for PMI on an interpersonal level. Participants in this study mentioned the attribution of mental illness to personal weaknesses or supernatural causes (both of which are linked to culture) by the people close to the PMI, which may result in the PMI facing greater resistance to seeking professional psychological help. Consequently, there is a delay in receiving formal treatment, and studies have shown that a greater treatment gap is associated with adverse outcomes [
59‐
61]. Such a finding lends credence to the fact that friends and families do influence an individual’s help-seeking intentions, thus reinforcing the importance of improving the mental health literacy of the population and addressing the cultural misgivings about mental illness in Singapore which leads to stigmatisation as discussed by Tan et al. [
44].
Our findings suggest that stigma also permeates the healthcare settings in Singapore, as reported by our participants who had witnessed instances of diagnostic overshadowing by other HP. This corroborates the evidence from a previous study that documented the stigma experienced by PMI in Singapore, where PMI opined that their opinions were often disregarded by the HP [
38]. In line with our findings, the literature suggests that diagnostic overshadowing is a global occurrence, which could delay consumers from receiving proper treatment and increase the risk of further health complications [
53,
54]. Although there are other possible causes of diagnostic overshadowing, such as when HP are facing time pressures or when the workload is hectic, the accounts provided by our participants seemed to imply that the diagnostic overshadowing in this context is due to stigma, in the sense that HP were unable to see beyond the PMI’s diagnosis. Another healthcare-related stigma that participants elaborated on pertains to HP’s inclination to reject providing care to PMI because of a desire for greater social distancing. Therapeutic pessimism is another manifestation of healthcare stigma identified in this study, with many participants intimating that PMI will not be able to fully recover. This aligns with studies conducted overseas, suggesting that it is not an uncommon form of stigma [
11,
62,
63].
As mentioned in the introduction, HPs may also contribute to the stigma towards mental illness, which in itself may present as a barrier to PMI’s recovery, and our study found that inadequacy in training was one of the key reasons for this stigma. Participants highlighted the issue of inadequate training in the mental health field, whereby many HP are thrust into the field without having adequate support. Some stated that when first joining the field, they had low perceived and actual self-efficacy, and a lack of knowledge with regards to PMI. In that case, HP at the nascent stage of their career are likely to be oblivious to their preconceived negative beliefs and attitudes towards mental illness. Moreover, they are also more susceptible to misinformation and misconceptions about mental illness from their peers and the media as compared to their more veteran peers as they are less likely to have developed the tools and first-hand experiences to counter misattributions. This was especially seen among professions whereby their training programmes do not allow for experiences with PMI – for instance, responses revealed that nursing programmes do not have mental health training before their posting to mental health services. The lack of proper training often leads to HP not being adequately prepared to interact with PMI or debunk negative attitudes and myths - these issues often lead to anxiousness and fear when interacting with PMI, resulting in a tendency to avoid PMI and desire for a greater social distance towards PMI [
11]. Studies have also shown that healthcare professionals hold more negative attitudes towards their patients when they perceive that interacting with them is difficult, which often leads to PMI’s feelings of frustration and rejection [
64‐
66]. As a result, this ultimately jeopardises the therapeutic relationship, adherence to treatment for PMI, and ultimately recovery [
26].
The study also explored associative stigma experienced by HP from the perspective of hindering recovery among PMI. Salient issues highlighted were the negative assumptions the public have about HP, and a general pattern of job devaluation experienced by HP. Similar studies have addressed this issue, whereby HP working closely with PMI are often viewed as less skilled and less competent than their counterparts [
19,
21,
67]. Halter [
18] described it as nurses in the mental health field seen as “not real nurses”, a similar issue that was brought up by a psychiatrist in this study [
19]. Furthermore, research encompassing medical students’ views has suggested that the general reputation of psychiatry is poor, citing reasons such as lesser respect and prestige compared to other specialities as focal reasons for opting to not specialise in psychiatry [
68,
69]. This is akin to some of our participants suggesting that they were discouraged from joining psychiatry during medical school. A recent Singaporean study revealed that while doctors in mental health settings were more likely to experience moderate stigma, nurses were more likely to experience both moderate and high associative stigma [
70]. Negative perceptions about these HP might spill over to their jobs and increase job stress [
20,
71]. Previous studies have emphasised the connection between associative stigma and burnout, dissatisfaction, and compassion fatigue, which negatively affects the way practitioners interact with PMI, jeopardizing the quality of care [
18]. Additionally, HP’s associative stigma has also been linked to higher levels of self-stigma among PMI [
20], which as aforementioned, is detrimental to the recovery process.
Lastly, our findings also unearthed practices at a structural level that HP perceived as discriminatory, and exacerbating the challenges that PMI face in their recovery. The first would be the need for mental illness declaration on the job application forms, which is fortunately not as concerning presently because, at the time of writing, the Tripartite Alliance for Fair & Progressive Employment Practices in Singapore had already introduced a guideline to safeguard fair employment practices which proscribes companies from asking about mental health history on their job application forms unless it is a job-related requirement [
72]. As mentioned by some of our participants, the need to declare one’s mental health history still has repercussions because purchasing insurance is still an area where PMI face structural discrimination for having a diagnosis. Anecdotal evidence suggests that having a psychiatric diagnosis often jeopardises one’s insurability even if their mental health condition does not implicate their physical health, and this could constitute as a barrier to help-seeking due to the aversion to being labelled with a psychiatric diagnosis [
73‐
75].
Perhaps a difficulty that insurance companies face in providing PMI with coverage for physical health problems is that people with serious mental illness are associated with a higher risk of physical comorbidity and a shorter lifespan [
76]. However, for insurance companies to exclude PMI who have sustained recovery and are otherwise physically healthy from getting insurance plans that provide physical coverage or to charge them higher premiums would be inequitable. It has been proposed by mental health advocates and stigma researchers for anti-stigma initiatives to not only concentrate on “soft goals” such as public education and changing attitudes but also to shift the focus towards addressing “hard goals,” in the form of legislative and policy change to promote social equity and improve the overall quality of life for PMI [
77]. As such, to mitigate this particular barrier to help-seeking, there may be a need for policymakers to press for legislative changes in the realm of insurance. For instance, insurance companies could shift towards a case-by-case basis to evaluate applications from PMI and be more transparent about their underwriting process, instead of rejecting PMI without providing concrete reasons. Such a shift could reduce stigma on a structural level and promote equity for PMI, concomitantly sending across a message that recovery is possible and that PMI are not markedly different from the lay public.
An interesting finding that our study came across is the stigma associated with IMH (the state mental hospital) which could potentially deter individuals from seeking help, or more specifically seeking help from IMH. An earlier local study showed similar results, where it was reported that for individuals with non-schizophrenia disorder, greater stigma was associated with being treated by IMH as compared to being treated in a university hospital [
78]. In contrast, individuals with schizophrenia in that study reported a greater degree of stigmatisation in general hospitals as compared to at IMH. Chee and colleagues [
78] posited that their finding might be attributable to the fact that there are disease-specific and institution-specific aspects of stigma because the proportion of patients with schizophrenia only comprises a fairly small percentage in the general hospital and so the demographic of psychiatric patients in the general hospital is more heterogeneous, whereas IMH comprises largely patients with schizophrenia as it caters to most of the persons with schizophrenia in the country. In our study, participants implied that many individuals are aversive towards IMH for they equate it to a “mad hospital”, and terms such as psychotic and madness are typical stereotypes associated with schizophrenia [
79,
80]. By juxtaposing the explanation by Chee and colleagues with this study’s findings, it can be postulated that the stigma towards IMH could very likely be because of an intertwining of disease-specific (schizophrenia) and institution-specific stigma. Another plausibility for this aversion towards IMH could be the fact that a general hospital treats a variety of health conditions, and one could better conceal their mental health condition by seeking treatment at a general hospital [
81,
82]. Nonetheless, it is recommended that more studies be carried out to affirm the hypotheses of this finding, as well as research for effective strategies to eradicate such stigma.
There is a growing body of research in Canada documenting the effective strategies and key ingredients for the reduction of stigma in healthcare settings [
11,
83], which includes educating HP on “what to say” and “what to do”. To attenuate the impact of healthcare stigma identified in this study, there is a need to also focus anti-stigma efforts on HP, and we postulate that it would be helpful to take reference from the work by Knaak and colleagues [
84]. For instance, teaching HP in the general healthcare system about “what to say” and “what to do” would arguably reduce HP’s feelings of inadequacy in working with PMI. Knaak et al. also advocated for social contact approaches with HP in a non-typical provider-patient interaction, such as having PMI share about their lived experience of illness and recovery as well as their experiences in healthcare settings. Such forms of social contact are likely to increase empathy and diminish fear of PMI. Conceivably, the reduction of stigma would also lead to a decrease in instances of diagnostic overshadowing or the tendency for HP to reject working with PMI.
Knaak and colleagues also proposed emphasizing that recovery is possible and demonstrating the impactful roles that HP play in this process [
11,
84], which could alleviate some of the pessimistic views about recovery held by HP. Implementing recovery-oriented models of care would probably be another effective approach to counteract therapeutic pessimism. This way, recovery would no longer be framed as an end state characterised by the decrease of symptoms and disabilities. Rather, when recovery is regarded as a process as in recovery-oriented practice, the aim would be to support PMI in a way to inspire hope and see beyond the illness, as well as giving more agency to the PMI in their recovery goals setting [
4,
55]. Moreover, some studies have shown that recovery-oriented practice is associated with better therapeutic alliance [
85,
86], and research has indeed evinced that better therapeutic alliance is linked to positive outcomes such as reduction of psychiatric symptoms and improvement in quality of life [
87], further substantiating the advantage of implementing recovery-oriented practice.
Additionally, the vulnerability of HP working closely with PMI to associative stigma calls for implementations that address the challenges that healthcare professionals might experience. It is important that healthcare professionals, especially those new to the field, are aware of such stigma, and able to identify how it affects their job-related tasks. Bladon suggested that one possible way of mitigating stigma is by celebrating the uniqueness of these professionals through public means [
88]. Emphasising the unique and positive contributions of HP working with PMI through public education does not only increase the positive identity of these professionals but also possibly can enhance client outcomes through reducing mental illness-related stigma and giving a platform for HP to copiously advocate for patient care [
89]. Even though associative stigma is experienced, it is essential that these HP still can maintain pride in the profession and acknowledge that the work that they do is valuable [
21].
Limitations
There are a couple of limitations pertaining to this study that need to be highlighted. Firstly, most of the participants in this study were affiliated with IMH, and it is possible that the findings of this study would not be generalizable to HP working in other hospitals or private settings. Secondly, the sample of this study consisted of HP from various occupations, and there might be unique viewpoints from the various specific occupations which were not elucidated in this study. Furthermore, since participation was voluntary, it is probable that many of our participants are strong advocates of anti-stigma work, and they may hold views that are disparate from those who are not. Lastly, although participants were assured of confidentiality, it is possible that they were not completely candid in their discussions and had withheld some personal views, which could be in part attributed to social desirability bias as well as a fear of expressing opinions that might have implicated other organizations or hospitals. Based on the above limitations, it is recommended for future studies to sample only HP of a particular occupation, or to include only HP from general hospitals and private settings, to allow for a more diverse understanding of how stigma influences recovery. These limitations notwithstanding, our study presents an early attempt to examine how stigma influences recovery from the perspective of HP, and also showcased important insights on the challenges that stigma poses toward recovery, the findings of which could inform policymakers of ways to improve the recovery of PMI.
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