An Exploration of Mental Health-Related Stigma in an Emergency Setting

Abstract

Mental health-related concerns are ubiquitous and deserving of the same compassion and support offered for other health problems. However, the scarcity of resources for mental health (MH) issues remains a complex public health problem. EMBER researchers sought to identify gaps in understanding of MH-related stigma in emergency departments (EDs) through interviews with (1) ED physicians/residents, nurses; (2) ED psychiatric physicians/residents, nurses; (3) protective services staff; and (4) patients and family members/support persons. Nine focus groups and 26 interviews were conducted with a total of 46 participants. Interviews/focus groups were coded using thematic analysis through research team discussion. Findings demonstrated structural stigma is a major barrier to accessing quality healthcare services and a key driver of interpersonal and intrapersonal stigma. Sustained, integrated interventions are needed to address key inequities, particularly in the model of care and service delivery, the culture of caring, in staff training, and in the ED physical space. Building trauma and resiliency-informed models of care was identified as an important foundational step in this process.

Appendices

Appendix 1

Focus Group/Interview Guide: Patient and Family

Introduction

• Introduce self.

• Explain format and content of the focus group/interview, including estimated time.

• Ask if participants have any questions about the study or consent form they completed.

• Explain that the interview/focus group will be recorded via Zoom (or audio recorder if in person).

• Ensure recording has been started.

Preamble for Facilitators/Interviewers

Thank you for agreeing to participate in a focus group/interview about mental illness-related stigma in the emergency department. As described in the information letter, the purpose of our study is to better understand the opinions, experiences, and perspectives of individuals and families who have sought help for a mental health or substance use concern in the emergency department. The information you provide is extremely important as the results will be used to identify and develop educational programs and other interventions to better support ED staff and serve patients.

We will go through a series of topics about mental illness and substance use-related stigma. We have some reflection and discussion prompts to help guide the discussion and get us going on each particular topic. There are no right or wrong answers. This is about your own perspectives and experiences. If you do not have an answer or do not want to answer a particular question or engage in discussion on a particular topic, you do not have to. We will only summarize what we have learned from all the focus groups and interviews we are conducting. If quotes from interviews/focus groups are used in knowledge translation activities such as reports or manuscripts, they will be de-identified.

Focus groups: Everything you discuss will be kept as private as possible for a focus group setting. We ask that you only use first names during the group session. We also ask you not to tell anyone outside the group what any particular person said in the group. However, we cannot guarantee that everyone will keep the discussions private.

[when participants are ready, turn begin recording and start the interview/focus group]

Topic 1: Let’s begin by talking about the concept of stigma and if and how you see it showing up in the ED. [Introduce concept of stigma: usually we think of stigma as the existence of negative or prejudicial attitudes, judgments, and behaviors directed towards people with mental health and substance use problems that result in poorer quality of care. We also acknowledge that these negative attitudes, judgments, and behaviors exist at three levels—at the level of the self (self-stigma and internalized stigma), at the public or interpersonal level (e.g., in client-provider interactions), and in structures (e.g., policies and practices of the ED and allocation of resources)].

Prompts:

Patients:

• Have you felt stigmatized when seeking help for a mental health or substance use concern? Do you see examples of stigma at the interpersonal level? Structural level?

• What about self-stigma? Do you feel comfortable seeking help from emergency room staff?

• Do you feel confident that you will receive the care you need when you seek help in an emergency room?

• What do you see as the biggest problems for stigma? What do you think are the biggest issues to address?

• Have you had scenarios where you have felt less stigmatized because of the action of healthcare providers? What are we doing right?

• Has stigma ever been addressed directly in your experiences in the emergency department?

• Do you see other patients being treated differently than you in the emergency department?

Family:

• Have you felt stigmatized when your family member sought help for mental health of substance use concerns?

• Have you felt that your family member was stigmatized when seeking help in the emergency department?

• Do you feel confident that your family member will receive the care they need if they seek help in the emergency room?

• In your experience has stigma towards mental health impacted the level of involvement you have in your family member care?

• As a family member of someone with mental health or substance use concerns, do you ever feel stigma towards yourself (intrapersonal stigma) because of this? What about public or structural stigma?

• What do you see as the biggest problems for stigma? What do you think are the biggest issues to address?

• Have you had scenarios where you or your family member have felt less stigmatized because of the action of healthcare providers? What are we doing right?

• Has stigma ever been addressed directly in your or your family member experiences in the emergency department?

• Do you see other families being treated differently than you in the emergency department because your family member is seeking mental health care?

Topic 2: Are there differences in the stigma expressed or experienced according to type of mental illness or SU, or other patient characteristics?

Prompts:

• Differences in the type or severity of stigma for different kinds of mental illness?

• Differences in the type or severity of stigma between mental illness and substance use?

• Differences in the type or severity of stigma towards some patients over others—e.g., indigeneity, homelessness, pregnant women/mothers, and others?

• If you have been to the emergency department more than once has your experience changed with multiple admissions?

• Has stigma or fear of stigma ever kept you from seeking help?

• Have you ever experienced physical concerns being ignored because of previous mental health concerns?

Topic 3: What are some of the main sources of stigma?

Prompts:

• Are there certain healthcare providers that have made you feel more stigmatized than others?

• What are the main attitudes or behaviors of staff that need changing?

• What has your experience with healthcare providers taught you about mental health?

• If you have been provided education in regard to mental health, was it delivered in a manner that decreased stigma?

• How does language influence the way you see stigma towards mental health? Are there common comments or slang that has been said to you/used to describe you that has been stigmatizing?

Topic 4: What do you think is needed in order to tackle the problems we identified today? [Note: we are looking to be as specific as possible]

Prompts:

• What do you identify as the most important learning needs for healthcare providers? Do these differ by occupation or role?

• Are there any specific interventions or approaches that you think would be important to educate staff about?

• Are there any new services or supports that you think are needed to help tackle the problems we have identified today?

• What are the most important priorities for change?

• Do you think that a peer support role in the emergency department would be helpful? Would this be someone that you would want to access?

Topic 5: How will we know if we are being successful?

Prompts:

• Priorities for evaluating or tracking improvements or changes; how would the patient/family experience change if we are successful?

• Examples of what success or improvement might look like?

• Vision for what a stigma-free ED looks like?

At end of interview:

• Thank for participation.

• Review list of resources with participants

• Remind participants of project contact info should they have any questions about the research.

• Ask if participants would be willing to participate in individual interviews, if needed.

• Ask if participants would be interested in phase 2 of project (provide brief description).

• Remind participants that electronic gift cards (chosen when they completed the survey) will be distributed via email within the next couple of days (or donated if that was their choice).

• Ask participants if they are willing to share the study information with friends or family that may be interested in the study.

Appendix 2

Focus Group/Interview Guide: ED Staff

Introduction

• Introduce self.

• Explain format and content of the focus group/interview, including estimated time.

• Ask if participants have any questions about the study or consent form they completed.

• Explain that the interview/focus group will be recorded via Zoom (or audio recorder if in person).

• Ensure recording has been started.

Preamble for Facilitators/Interviewers

Thank you for agreeing to participate in a focus group/interview about mental illness-related stigma and learning needs. As described in the information letter, the purpose of our study is to better understand the opinions, experiences, and perspectives of people who work in the ED and who care for people with mental health or substance use problems. The information you provide is extremely important as the results will be used to identify and develop educational programs and other interventions to better support ED staff and serve patients.

We will go through a series of topics about mental illness and substance use-related stigma. We have some reflection and discussion prompts to help guide the discussion and get us going on each particular topic. There are no right or wrong answers. This is about your own perspectives and experiences. If you do not have an answer or do not want to answer a particular question or engage in discussion on a particular topic, you do not have to. We will only summarize what we have learned from all the focus groups and interviews we are conducting. If quotes from interviews/focus groups are used in knowledge translation activities such as reports or manuscripts, they will be de-identified.

Focus groups: Everything you discuss will be kept as private as possible for a focus group setting. We ask that you only use first names during the group session. We also ask you not to tell anyone outside the group what any particular person said in the group. However, we cannot guarantee that everyone will keep the discussions private.

[when participants are ready, begin recording and start the interview/focus group]

Topic 1: Let’s begin by talking about the concept of stigma and if and how you see it showing up in the ED. [Introduce concept of stigma: usually we think of stigma as the existence of negative or prejudicial attitudes, judgments, and behaviors directed towards people with mental health and substance use problems that result in poorer quality of care. We also acknowledge that these negative attitudes, judgments, and behaviors exist at three levels—at the level of the self (self-stigma and internalized stigma), at the pubic or interpersonal level (e.g., in client-provider interactions), and in structures (e.g., policies and practices of the ED and allocation of resources)].

Prompts:

• Do you see examples of stigma at the interpersonal level? Structural level?

• What about self-stigma? Do you think staff with MH problems feel safe disclosing or talking about their problems to colleagues? Feel comfortable seeking help?

• Have you ever sought help for, or felt stigmatized due to, a mental health concern?

• Have you ever had any experiences where you believe that stigma towards mental health may have affected quality of care or patients’ health outcomes?

• What do you see as the biggest problems for stigma/What do you think are the biggest issues to address?

• What are we doing right?

Topic 2: Are there differences in the stigma expressed or experienced according to type of mental illness or SU, or other patient characteristics?

Prompts:

• Differences in the type or severity of stigma for different kinds of mental illness?

• Differences in the type or severity of stigma between mental illness and substance use?

• Differences in the type or severity of stigma towards some patients over others—e.g., indigeneity, homelessness, pregnant women/mothers, and others?

• What do you think is driving the stigma expressed (intersectionality, language, and culture)?

• What about within the workplace?

Topic 3: What are some of the main sources of stigma?

Prompts:

• Link between provider stress (e.g., occupational stressors, burnout, and vicarious trauma) and stigma?

• What are the main attitudes or behaviors that need changing?

• What about policies or practices? Models of care?

• How does language influence the way you see stigma towards mental health? Are there common comments or slang that have been adopted that promote stigma?

Topic 4: What do you think is needed in order to tackle the problems we identified today? [Note: we are looking to be as specific as possible]

Prompts:

• What do you identify as the most important training or learning needs? Do these differ by occupation or role?

• Are there any specific interventions or educational programs or approaches that you think would be important to implement?

• Are there any new services or supports that you think are needed to help tackle the problems we have identified today?

• Need for inward facing training (interventions to support well-being of staff or to reduce stigma within the workplace) versus outward facing (training or education re. patient care)?

• What are the most important priorities for change?

Topic 5: How will we know if we are being successful?

Prompts:

• Priorities for evaluating or tracking improvements or changes?

• Examples of what success or improvement might look like?

• Vision for what a stigma-free ED and workplace looks like?

At end of interview:

• Thank for participation.

• Review list of resources with participants

• Remind participants of project contact info should they have any questions about the research.

• Ask if participants would be willing to participate in individual interviews, if needed.

• Ask if participants would be interested in phase 2 of the project (provide brief description).

• Remind participants that electronic gift cards (chosen when they completed the survey) will be distributed via email within the next couple of days (or donated if that was their choice).

• Ask participants if they are willing to share the study information with colleagues that may be interested in the study.