Up to 80% of Americans will experience a diagnosable mental health condition at some point during their lives, whether they know it or not. While other countries like the United Kingdom and Canada have begun taking massive action on the issue when it comes to the workplace, the U.S. is just at the beginning stages.
Employers might take action when they see that mental health conditions and substance abuse cost employers $225.8 billion every year. But what is often more difficult for employers to see is how mental health stigma plays out in their workplace, what exactly the stigma is, and what it looks like. If you are going to find ways to resolve a problem, you first have to understand exactly what the problem is. That’s why we sought out professor Stephen Hinshaw, a renowned mental health stigma expert to have a conversation about what stigma when it comes to mental health in the workplace, and how employers can lessen it and even change stigma within their organizations.
Q: One of the major stumbling blocks for many employees who are managing a mental health condition is the social stigma attached. What is mental health stigma and how does it affect the workplace today in the U.S.?
Hinshaw: “Stigma, like many, if not most, psychological terms is Greek. In ancient Greece “stigma” literally meant that you were branded in an unfavored group in society. A mark was literally burned into your skin so that it was clear who was in the ingroup and outgroup. Most stigma today is not a literal brand or mark—it’s a figurative and psychological one. Stigma today says, “We know you are a member of this group, which means there is something inferior about you and we need to keep our distance.” As of 2018, the three most stigmatized groups in the U.S. are the homeless, substance abusers, and mental illness. Believe it or not, left-handedness used to be stigmatized, but the social norms and beliefs have changed so that today it might signal that you have great spatial ability and might go to MIT. When social norms change, what was formally stigmatized may not be anymore. We haven’t made fundamental strides on the mental illness stigma in the U.S. over the last 100 years, but that doesn’t mean that we can’t change the social norms now.”
Q: So what you just described is the social stigma of mental health, but there is also self-stigma that occurs. What is self-stigma and how does it come into play for employees managing mental health conditions in the workplace?
Hinshaw: “First published in 1954, there was a book by a famous American psychologist named Gordon W. Allport called “The Nature of Prejudice.” This book still holds true today. One of Allport’s premises was if society shows prejudice against a certain group, it is apparent what the stereotypes and stigmas are. We previously learned of them through campfire stories, and today it’s Twitter Feeds. Inevitably, according to the premise, people in the outcast groups are going to internalize the stereotypes and stigmas they are seeing and take on the negative characteristics the stigma says they “deserve.” This is what we call self-stigma.
While self-stigma is likely when a group is consistently castigated, if members of that group bond with one another, show solidarity, and demand rights, self-stigma is lowered. This is the reason why the black power movement, women’s movement, and gay pride movement are important to our society over the last decade and have significantly reduced self-stigma and prejudice for members of those groups. A question for you now: What has been the primary group until very recently you never wanted to be associated with? The answer most would give is the mentally ill. To admit that you have a mental illness and join forces with others with depression, bipolar, PTSD, etc. would be unthinkable. With self-help and advocacy groups thriving in recent years, we now know that self-stigma for people with mental health conditions is not inevitable.
Self-stigma in the realm of mental health is particularly devastating because there is good evidence that the degree to which you self stigmatize predicts two outcomes:
This is a vicious cycle. If you believe you’re not deserving of treatment, then you don’t get engaged in treatment, and you continue to suffer from the symptoms, and people around you think you are malingering—so the stigma intensifies. Decreasing self-stigma and fostering engagement in treatment is the clear antidote here.”
Q: Are employees who wish to disclose their condition to their employer protected by the Americans with Disabilities Act?
Hinshaw: “The Americans with Disabilities Act (ADA) says that discrimination of people with physical or mental disabilities is illegal in our country in the workplace or in public. But does that mean if you are applying for a job that you tell the prospective employer with whom you are interviewing? Before you are employed, there is no guarantee that you are protected at that time if you are not an employee in that workplace yet. So, the disclosure of mental health in the workplace becomes a big issue.
If I am an employee, does that mean I carry a sign that says “I have depression”? Maybe I don’t want everyone to know that about myself before they’ve even been introduced to me. Disclosure is a matter of timing, rehearsal, and support. What we can’t have the default be in workplaces is where you are not allowed to talk about it. So maybe I’m strategic and I’m not disclosing my mental health condition during the job interview, but if I get the job and I’m realizing I need accommodations, then I should be able under the ADA to get reasonable accommodations.
Here’s the paradox of paradoxes. Until fairly recently under the ADA, the vast majority of claims were from people with physical disabilities and led to costs to employers like widening ramps, installing elevators, etc., yet very few people with mental health conditions were creating claims. Accommodations for mental health would be things like flex time, work from home days, more vacation days, etc. The cost to organizations by in large for accommodating mental health is relatively trivial compared to physical health, but the self-stigma is so great that people don’t want to be known as morally right, or have poor character because they “can’t cope like everyone else can.” These are some of the likely experiences those with mental health conditions in the workplace will face.”
Q: Part of the stigma comes from a lack of widespread understanding that mental health is a spectrum. We often go immediately to extreme cases in our minds. Can you touch upon what it means that mental health is a spectrum and how companies might think about policies that accommodate everyone?
Hinshaw: “This is an important question. I was in grad school and I learned that you had mental health conditions or you didn’t. At the more extreme ends of the spectrum, yes you have individuals who experience severe symptoms. But what about many workers in tech? You’ll see folks across Silicon Valley on the spectrum who might be more analytical, rather than social—and yet they thrive. We now know that mental health is not a yes or no—it’s a spectrum. It’s the same for blood pressure. If I’m 139 over 89, I am not quite 140 over 90, but my doctor might have me implement lifestyle changes. In science, if something does exist on a spectrum, where do you draw the line? Do I have hypertension or not? It can be arbitrary but also has two big implications:
Infusing empathy and compassion into workplace culture seems beneficial in creating mentally healthy workplaces. Last May, when I was on the panel with Arianna Huffington at Mind Share Partners’ Mental Health at Work Mini-Conference, she mentioned employers asking who an employee is physically, emotionally, mentally, spiritually. Adding an entrance interview with this in mind could lead to resolving issues up front, along with the realization that not every employee can be accommodated fully.
Q: With the hustle culture at an all-time high, employees experiencing mental health conditions like anxiety often hear the critique from colleagues that goes something like, “Well I’m stressed out at work too, but I’m not asking for special treatment. Can’t you just tough it out.” Why can’t people with diagnosable conditions just “tough it out”?
Hinshaw: “Nina, I see you wear those contact lenses, can’t you just make your eyes work harder? Why would you need those? It’s absolutely unthinkable to say that, right? Why would you need that wheelchair, just stand up and walk! We feel differently as a society about physical limitations than we do about mental ones because we are all raised to think that we can control our behaviors and emotions 100%. Remember “4 eyes”? It used to be more stigmatized, but now no one cares, and glasses can even be cool.
We seem, however, to criticize people who can’t overcome wherever they are on the mental health spectrum on their own. On the extreme end, people with bipolar disorder are not going to have a very productive or even long life if they don’t get therapy and medications to manage their symptoms. But yet, we still feel that people can control their emotions and behaviors far more than they can control all of their physical attributes and qualities. And that’s where we have to do education. And that’s where we have to increase compassion.”
Q: You share in your latest book how your father suffered major bouts of psychosis that kept him periodically hospitalized during your childhood. What was it like growing up experiencing the ups and downs your father faced suffering from severe mental illness and being kept in the dark about what was really happening? How did this impact your work and research on mental health stigma?
Hinshaw: “Growing up, my dad would disappear for 3 to 6 months, and at one point even a full year—and nobody talked about it when he left, and nobody talked about it when he came back. We had to pretend it never happened. I didn’t know his lead doctor had told him and my mother that “if you ever tell your children about our life long mental illness they will be permanently destroyed” and forbid them from mentioning the topic.
Would an oncologist today say “you are forbidden from telling your children about your breast cancer or prostate cancer”. That doctor would be sued for malpractice—of course the family has to know. However, back in the 1930-50s, you would never put cancer in the obituary of a relative who died from it because “it was a shameful disease you brought on yourself.” Our attitudes towards cancer have radically changed.
But we aren’t there yet for mental illness. We’ve moved past the “evil spirit” beliefs, but society still believes that people can help it. Society also believes the opposite that people with mental health conditions must have been born with a different set of genes. You would think that second one might reduce the blame like it does for physical illness, but for mental illness, if we believe it’s complete biochemically, we blame them less, but then we also believe they will never get better and keep our distance. It’s like your character is flawed at the level of your DNA.
When I was a boy, I thought it was my fault dad disappeared. When kids don’t receive a discussion about difficult events, they tend to internalize. Dad finally talked to me about what was going on once I started college. It motivated me to go into psychology and I understand why he did what he did and that it wasn’t my fault. But, I was also terrified I’d be next. I wasn’t talking with anyone about what I experiencing because I thought it was shameful. I had internalized the same silence and stigma. And only as I got older I realized I wasn’t alone in this. Many kids grow up in homes with mental illness, and it motivated the activism I do now. I learned that talking about your experiences and putting a name on it helps prevent the internalization and self-stigma.”
Q: It sounds like specifically in workplace culture, for anything to change there needs to be a conversation and mental health has to be okay to talk about.
Hinshaw: “If we are in the default position where it’s too shameful to talk about, we’re lost. We have to get away from the noxious default that you can never talk about it because it shows “you’re weak.” Mental illness isn’t rare, especially when we think of it in the spectrum. We have to change work culture so that it’s acceptable to believe that you are not weak, or will get in trouble, or will be treated differently by talking about your mental health. And workplaces need to communicate and encourage that it’s okay to get support and treatment.
Creating a culture where we can’t talk about mental health is shooting ourselves in the foot in being a productive society. We are conditioned to go to extremes in our mind like violent school shooters, severe schizophrenia—that’s a tiny percent of people with very severe, untreated chronic mental illness. What about everyone else? What about the 1 in 5 women and 1 in 10 men in the U.S. that will have major depression in their lifetime? Mental health is everywhere, but you wouldn’t know it because we bury it because we don’t want to be perceived as weak, and we don’t want to be outcast.”
Q: You just mentioned we tend to bury this topic around mental health. Recently we’ve seen public figures mental health stories, such as an Anthony Bourdain and Kate Spade, all over the media. What do you think these recent stories say about mental health in high performers, entrepreneurs, and those who accomplish a lot in business?
Hinshaw: “Well, this is a huge issue. We don’t know what went on for years in the minds of Kate or Anthony, but we do know that last summer, this was a shock to a whole lot of people. Fiscally successful, public figures in the prime of their lives and careers, ending their lives. To me, what’s really interesting is that right in between Kate and Anthony’s passings, the CDC released their 20-year update on U.S. suicide rates. Data now uncovered that kids, teens, young adults, middle age adults, older adults, males and females, rich and poor, all races—suicide rates all went up substantially for everyone over the last 20 years.
It might take a celebrity suicide, and it might take someone who is clearly known for productivity and notoriety for it to raise awareness to say “if they didn’t feel life is worth living what about me?” What we need to go beyond is star power. John Nash, “A Beautiful Mind”, received a Nobel prize in economics for his work on game theory and simultaneously lived a life of chronic schizophrenia. Though the book and movie did a lot to raise public awareness, in some ways, it told society that if you have schizophrenia, you either win a Nobel prize or you are homeless under the freeway. It presented this idea with no middle ground.
The middle ground conversations need to be fleshed out by everyday narratives and stories. That’s what put breast cancer on the map. Women started sharing stories about treatment, what life was like, and juggling it all. It’s everyday trials and tribulations. The more those are a part of the national dialogue, whether it’s about breast cancer, schizophrenia, major depressive disorder, PTSD, or any other major mental or physical health condition, the more awareness will raise in people who know someone close to them who had x, y, and z. Mental illness affects nearly half the population at some point in their lives but we still don’t talk about it in a normalized way. That’s the paradox and tragedy.”
Q: With the mental health movement at the beginning stages in the U.S., do you think it’s possible for this society and its businesses to fully remove the stigma around mental health?
Hinshaw: “First, that is my life’s goal. Second, I am a realist enough to know that this is a long battle. Let’s look back since the Civil Rights Act. Have we eliminated racial prejudice in the U.S.? Of course not. Difficult social problems like racial injustice, mental illness, and climate change are going to take policy efforts top-down. I think we can put a major dent in mental health stigma moving forward over the next decades. I don’t know if we will eliminate it by 2050, but I think we can make strides, and I think we are already starting too. Social problems don’t take one campaign and then they are gone. They take sustained efforts and multiple levels of any society over a long period of time. This includes businesses within society. We all need to do our part.”
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