In a healthcare setting, mental illness stigma results from labelling patients with mental illness as time-consuming, unpredictable or unfixable. Perceived lack of self-efficacy in healthcare providers further perpetuates stigmatizing attributions. Educational interventions to reduce stigma may be more effective if they focus on patient-provider relationships and foster humanizing labels while increasing empathy skills. Work with individual providers is not enough to reduce stigma without considering socio-cultural influences.

Despite increasing attention and levels of public acceptance about the underlying cause of mental illness, mental illness stigma (negative attitudes and behaviours towards individuals with mental illness) continue to adversely impact patients and families [1–4]. A recent review found that stigma decreases help-seeking behaviours among individuals with mental illness(es) [5]. Stigma has been associated with a low quality of life and well-being [6, 7], persistent stress [8], interference with recovery [9], lower treatment adherence [10], shortened life span [11] and suicide [12]. Stigma also adversely impacts family relationships and contributes to caregiver fatigue [13].

Explanatory frameworks for stigma vary, ranging from individual cognitive models to motivational and structural models.[14, 15]. In particular, the work of Scheff and Goffman in the 1960s proposed modified labelling theory, emphasizing that stigma is an individual process enacted through social interactions [16–20]. Further scholars have refined Goffman and Scheff’s original work, describing stigma as resulting from converging forces including labelling of difference, linking of labels to undesirable characteristics, placement of labelled persons in distinct categories to accomplish separation and, lastly, the experience of discrimination that leads to unequal outcomes [17, 18].

Global efforts to reduce mental health stigma have been implemented by governments in most Western countries including the European Union, Australia, the USA and Canada [16]. Current models for stigma reduction include education and social contact. Education plays a role in reducing stigma by increasing knowledge about mental health and fostering counter-stereotypes about individuals with mental illness [21]. The success of stigma reduction interventions is typically measured by psychometrically validated scales at the individual level and through conceptual domains such as behaviour, penetration, psychological perspective, and knowledge at organizational and population levels [21]. While the public believes that stigma-reduction efforts have produced decreased stigma, research suggests that stigmatization of mental illness has shown a corresponding increase, which is perpetuated by associations between mental illness and dangerousness [22].

Existing research on stigma reduction education reveals several constraints on the power of current approaches to effect meaningful change. Educational interventions that provide information to dispel stereotypes regarding mental illness are considerably less effective for individuals who exhibit greater prejudice [14]. In contrast, social contact-based interventions that promote interpersonal contact with patients with mental illness are more effective than education alone [23, 24]. Social contact-based interventions have limited effect unless the contact is in person [25], the interactions are rewarding and enriching [16], and the individuals encountering each other are of equal power [26, 27], and pursue rewarding activities [28] towards a common goal [29]. Creating authentic learning environments that equalize the power differential between patients and healthcare providers is challenging. In most healthcare settings, patients and providers are rarely matched to each other, and when patients suffering from mental illness present in emergency or acute-care settings, there can be conflicting agendas and goals.

The success and sustainability of educational and contact-based interventions in healthcare organizations are therefore limited. Contact with patients with mental illness can lead to both positive and negative experiences for healthcare providers. If their experience reinforces their negative stereotype that patients with mental illness are dangerous, they may potentially further stereotype all patients with mental illness. Additionally, many interventions fail because they occur in organizational or sociocultural contexts that do not adequately address socio-cultural or societal influences [21]. A recent review of stigma reduction interventions in healthcare students and professionals found that education and contact-based interventions are often difficult to sustain, which raises questions as to whether cost of implementation may outweigh benefits [30].

We sought to address these limitations by considering deeper levels of stigma that may exist outside of conscious awareness. Implicit attitudes towards mental illness are gaining increasing recognition in the literature [31–35]. Since explicit attitudes and behaviour are often poorly assessed [36, 37], implicit measures such as the implicit association test (IAT) may play a role in future stigma reduction efforts. The IAT is an online tool that serves to bring an individual’s implicit attitudes regarding mental illness into their conscious awareness. The test pairs concepts with groups utilizing reaction time as primary outcome. Shorter latencies indicate stronger implicit associations. For example, the IAT measures associations between ‘dangerousness’ and either ‘mental illness’ or ‘physical illness’ [38].

Given the constraints of existing educational and contact-based interventions, our study sought to explore the social process of stigma including how stigmatizing attitudes and behaviours influence the healthcare experience. By exploring implicit stigma in a specific and targeted setting (paediatric emergency department) with diverse participant groups, we endeavoured to develop a deeper understanding of mental illness stigma to inform future educational interventions and reduce the adverse impact of stigma on patient outcomes.

We utilized a constructivist grounded theory approach to explore the process of stigmatizing attitudes and behaviours in an emergency setting. Constructivist grounded theory is well suited to explore a social process that is not currently explained by a well-established theoretical construct [39].

Patients and families who utilize emergency department mental health services often report that stigma adversely impacts their experience [40, 41]. We chose the paediatric emergency department of an accredited Canadian academic health science centre to understand the process of stigma in a discrete environment that was representative of the gateway to acute-level healthcare. The principal investigator (JS) also maintains insider status as a child and adolescent psychiatrist and the research question emanated from observations during clinical activity regarding differential treatment of patients with mental illness and physical illness in this specific environment. A paediatric setting provided an opportunity to study the complex interplay between patients, caregivers and providers and was an ideal setting due to insider status, size, and scope of the clinical environment. Approval was obtained from the Western University Research Ethics Board (105881) to conduct the study.

Consistent with grounded theory principles, we used a purposeful, theoretical sampling approach. Our initial recruitment and interviews focused on patients and caregiver participants, addressing critiques of stigma research being uninformed by the lived experiences of patients and caregivers [42, 43]. We then invited multiple stakeholders including administrative staff, nurses and physicians through recruitment notices posted internally and through electronic means. Participants were asked to participate in 60-minute semi-structured interviews to explore stigma in a hospital setting. Analysis of our early interviews with patients and caregivers revealed the importance of clerical registration staff as part of the experience of stigma in a hospital setting. Therefore, we expanded our sample to include emergency department registration clerks.

Since our study was designed to move beyond existing stigma reduction paradigms and consider implicit attitudes about mental illness, we utilized a novel qualitative methodology that incorporated the mental illness IAT as an interview prompt. The use of specific triggers is a commonly used technique in grounded theory methodology to facilitate deeper discussion. Each interview began by reviewing a letter of information describing the nature of the IAT and that participation was voluntary. To promote safe disclosure, participants were advised that their IAT results would remain confidential and interviewers were prepared to debrief any potential emotional reactions regarding IAT results. In all interviews, participants were asked about the experience of taking the IAT and whether they felt that implicit associations played a role in mental illness stigma. In this study, the IAT was used as a prompt to trigger a richer interview about the process and experience of stigma and IAT results were not a part of the analysis. A separate study focused on participant responses to the IAT.

The team was composed of the principal investigator (JS), a child and adolescent psychiatrist, faculty member and PhD candidate in health professions education, as well as a paediatric emergency clinical leader (RL), research staff (KM), a clinical social worker (AC), and two registered nurse educators (AM and CS). Co-investigators also included CW who has expertise in health professions education research and qualitative research methods. Team members JS, KM, AM and CS conducted 24 individual semi-structured interviews from June to December 2015. To minimize power differential, a physician (JS) conducted the physician interviews, research staff (KM) conducted patient/caregiver interviews and nursing staff (AM and CS) conducted nursing and administrative staff interviews. Interviews followed a discussion guide developed from the initial literature review which included broad and open-ended questions exploring definitions of stigma, effects and possible interventions. The discussion guide was adapted iteratively as the study proceeded in accordance with a constructivist grounded theory approach [39].

Initial analysis was conducted by a team consisting of JS, KM, AM, and CS, beginning with line-by-line coding and utilizing constant comparative analysis to develop focused codes and working towards major themes. Key themes were shared with the entire team as analysis shifted to axial coding and the development of an explanatory theory that accounted for possible relationships between themes. Data collection continued until authors felt that sufficient data had been collected to enable a coherent and logical conceptual understanding of the process under study [44]. Findings were shared with a representative sample of participants via email to achieve triangulation. Participants from each group described general agreement with the synthesis of the results.

A total of 24 interviews were conducted across the various stakeholder groups. Four interviews were with service users (SU), 6 with caregivers (CG), 2 with clerical staff (CS), 2 with administrative staff (AS), 5 with physicians (MD) and 5 with nursing staff (RN). Participants were assigned a number based on the stakeholder group to which they belonged.

Broadly, most participants defined stigma as negative attitudes towards patients with mental illness and the behaviours that result from those attitudes. When asked to describe a situation that included stigma, participants described situations that fit with general definitions without contextual nuances specific to the emergency department. We found that key sociocultural and organizational influences on stigma – including media, history and a lack of mental health resources – contributed to fear and helplessness in providers. Patients with mental illness were labelled as time-consuming, dangerous, unpredictable and unfixable which led to avoidance behaviours. A perceived lack of self-efficacy in providers perpetuated frustration and helplessness, and further contributed to stigmatizing labels. Participants endorsed education as a key element of stigma reduction and focused on interventions at the patient-provider level.

Existing research emphasizes that educational interventions that equalize power dynamics and address patients’ experiences of discrimination and prejudice may reduce stigma [58, 59]. Our findings add that provider self-efficacy may also be a useful target of educational interventions; deliberate efforts at perspective-taking and engagement, for example, may enable providers to more effectively mitigate the power differential that feeds stigma. Educational interventions that emphasize self-awareness and social perspective-taking may also limit unintentional avoidance behaviours. In short, interventions rooted in empathy may counter stigma. That healthcare providers, caregivers, and service users perceive that the relational aspects of care fall within their influence suggests that meaningful change in this realm is possible.