Stigma due to their work in mental health, among mental health professionals in Sri Lanka

Abstract Background Stigma related to mental health is not limited to individuals with mental illness or their families; health professionals working in mental health are also affected by it. Stigma among mental health professionals may lead to lack of work satisfaction, and poor recruitment and retention of personnel in the mental health sector resulting in poor mental health care. Stigma among the health professionals in Sri Lanka has not been studied adequately.


Introduction Stigma associated with mental health
In Sri Lanka, neuropsychiatric disorders are estimated to contribute to 11.5% of the total burden of disease, and only a minority of these patients receive adequate treatment (1). Stigma has been identified as a main contributor for the treatment gap in mental health (2). Stigmatizing and stereotypical views about mental illness include views that patients with mental illness are dangerous, unpredictable, difficult to communicate with, cold hearted and unfeeling, and that they perceive the world in a different way to 'healthy' people; and many of these views are often internalized by patients, who may then believe that they are less valued because of their psychiatric disorder (3). This in turn may contribute to increased social isolation, unemployment, poor functionality and poor treatment adherence in patients with mental illness (4,5). It has been well documented that those who associate with individuals with mental illness also face stigma and discrimination (6). Samarasekara et al., reported stigma is not restricted to mental illness in Sri Lanka, but that it is very much associated with the family unit, and for example, if one person in the family has a mental illness it is very difficult for other people in the family to get married (7).

Stigma among mental health professionals
Just as stigma affects family members of the mentally ill, mental health professionals too are subjected to stigma. Goffman has described the stigma associated with http://doi.org/10.4038/sljpsyc.v9i1.8174 This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution and reproduction in any medium provided the original author and source are credited.
Stigma due to their work in mental health, among mental health professionals in Sri Lanka mental health professionals as 'courtesy stigma' -stigma by association (8).
Lai et al., reported that around 60% of mental health professionals including doctors had been laughed at their line of work, while 30% had been discouraged by family members from joining the mental health profession (9). It is further reported that 51% of psychiatric nurses and 15% of psychiatrists would make a different choice of career of if they were given a chance again. On the other hand, mental health clinicians including psychiatrists are supposed to be the main guardians against stigma towards people with mental illness. However, mental health clinicians themselves may become perpetrators of stigma by harboring negative attitudes towards mental illnesses and mentally ill (4).
Fernando et al., reported higher levels of stigma towards patients with mental illness among Sri Lankan doctors and medical students when compared to similar population elsewhere (10). A majority of Sri Lankan doctors and medical students believed patients with mental illness are dangerous, unpredictable, and difficult to communicate with and that they perceive the world differently.
Samarasekara et al., in a study involving community mental health workers reported that within the Health System Services, mental illnesses were not considered to be a priority in Sri Lanka compared to other kinds of health services, leading to community mental health workers feeling stigmatized (7). They reported being laughed at by colleagues due to their work in mental health and less valued as health care workers by the wider community.
While it is clear that stigma associated with mental illness is high in Sri Lanka, only a few studies have investigated this area (11) and stigma associated with mental health professional has not been studied in detail in Sri Lanka.
This study was aimed to determine the extent of stigma, nature and associated stigma and the relationship between stigma and job satisfaction among mental health professionals in Sri Lanka.

Setting and context
This descriptive cross-sectional study was conducted in the mental health units of National Hospital in Sri Lanka, Colombo North Teaching Hospital, Ragama, Base Hospital, Panadura and the National Institute of Mental Health, Angoda. Purposive sampling method was used to recruit consultant psychiatrists, postgraduate trainees, medical officers, nursing officers, social workers and ancillary staff who have worked for more than 6 months in mental health sector.
The study was conducted by using a self-administered questionnaire. Data was gathered from the consenting participants using a specifically designed, pilot tested questionnaire containing questions on participants' demographic details, stigma related to work in mental health and job satisfaction. The stigma and the job satisfaction were evaluated through a 5-point Likert-rating scale.

Results
A total of 125 participants including 6 consultant psychiatrists, 14 post graduate trainees, 17 medical officers, 51 nurses, 5 social workers and 32 ancillary staff members. A majority of participants were females (64%) and the average age was 39.3 years. Results are summarized in table 1. In this table, strongly agree and agree responses have been combined as agree and similarly strongly disagree and disagree have been combined as disagree.
A majority of participants (56%) reported that others think less of them as professionals due to their work in mental health. However, only 18% reported that they would conceal the fact they work in psychiatry due to others' reactions. Seventy-three respondents (58%) were either attacked or threatened with physical violence at workplace. Most victims were nurses and ancillary staff (p<0.05). Only 24% participants felt that they are less able to earn money because they work in mental health and none of the psychiatrist believed their earning capacity is negatively affected because of the specialty they have chosen. Only 34% indicated they would prefer to work in other branches of medicine, if given a chance, and most of these were ancillary staff members and nurses (p<0.05). An overwhelming majority (88%) reported high job satisfaction and the satisfaction was highest among psychiatrists (p<0.05).

Discussion
These findings indicate that associative stigma among mental health clinicians, and stigma due to their work in mental health among mental health professionals, is significant in Sri Lanka. But this does not yet appear to have turned into internal stigma, as suggested by only the few who reported being reluctant to be identified as mental health professionals. This may explain the high job satisfaction among mental health clinicians. The job satisfaction rate reported by our respondents is in direct contrast to what is reported in other countries. However, it is concerning that a significant proportion of Sri Lankan nurses and ancillary staff working in mental health was not satisfied with their jobs. The violence they experienced at their workplace may have contributed to this finding (14). A majority of nurses and ancillary staff had experienced physical violence at the work place. It is estimated that 50% of healthcare workers in other countries, are physically assaulted at their workplace, and nurses are three times more likely to experience violence compared to other professional groups (15). This highlights the need to strengthen work safety, and change attitudes towards zero tolerance to violence. Studies have proposed eliminating risk factors in the work environment, provision of authoritative guidelines, anti-violence training and change of attitudes towards work safety, as possible measures to minimize violence at the work place (16). While some hospitals in Sri Lanka have taken progressive steps towards reducing violence, other hospitals have a long way to go.

Limitations
The validity of findings of this study is limited by the small number of participants, the purposive sampling method, the study setting being restricted to a few hospitals in the Western province and exclusion of Tamil speaking clinicians.

Conclusions
The experience of stigma and dissatisfaction with work among mental health professionals, particularly nurses and ancillary staff, in Sri Lanka is common. Remedial measures to reduce violence at the work place, reduce courtesy stigma and increase the job satisfaction among mental health clinicians may improve the service delivery towards those with psychiatric disorders in Sri Lanka, which in turn may help reduce the mental health gap.