In the UK, disabled people are almost twice as likely to be unemployed (6.9%) as non-disabled people (3.6%). In Scotland, people with mental illnesses and learning difficulties are now the largest proportion of the disabled population, with over 35% of disabled people claiming mental health issues as their main disability. Despite positive policy and action focusing on public mental health, equality and human rights, people who have mental health problems continue to experience poorer employment outcomes (Cummins, 2023; Deloitte, 2024; Lagunes Cordoba, 2023).
Research by See Me (The Scottish Mental Illness Stigma Study, 2022) identified stigma in employment as a major concern to those living with mental health problems in Scotland. Participants reported experiencing stigma and discrimination in employment processes such as being asked to disclose mental illnesses on application forms. This served as a barrier to employment and was perceived to lead to assumptions and judgements by employers about their abilities.
To try to combat this, Janssens et al. (2023) evaluated the feasibility of a stigma awareness training and decision aid tool (Conceal or Reveal, Henderson et al., 2013) for employment specialists to use with clients with experience of mental health problems.
The disclosure dilemma: is it best to conceal or reveal mental illnesses when applying for a job?
Methods
The authors conducted a mixed methods study, gathering process evaluation data using questionnaires (baseline, 6 months and 12 months) and telephone interviews, as well as exploring six process components; recruitment, reach, dose delivered, dose received, fidelity and context (Steckler & Linnan, 2022).
Evaluation data was gathered alongside a cluster Randomised Controlled Trial (RCT), conducted between March 2018 and July 2020. In total, eight organisations participated: four organisations were randomised to the intervention group and four organisations to the control group.
The study included two groups of participants:
- Unemployed people with (self-diagnosed) mental health problems receiving social benefits (‘clients’)
- Employment specialists working at local municipalities who provided clients with guidance to find paid employment (‘employment specialists’).
The stigma awareness training for employment specialists consisted of three meetings of two hours, guided by 2-3 researchers and was delivered in groups of 4-12 participants at their own organisation. The conceal or reveal (CORAL) tool was introduced in the first meeting and participants were encouraged to use it in further training sessions.
Results
In total, 76 clients participated in the intervention, 58% of which identified as female, with a mean age of 37.4 years. Depression (26%), autism spectrum disorder (18%) and burnout (16%) were the most frequently self-reported conditions. Thirty-five employment specialists took part and they had a mean age of 42.7 years, with 7.7 mean years of experience working with clients with mental health problems. Overall, only 18% of all recruited clients (428) were reached (76); the most effective recruitment strategy was by employment specialists in one-to-one contact (67%).
Engagement with the tool was relatively low. Only a minority of clients and employment specialists had discussed the tool together (16-18%). Engagement of employment specialists with the tool decreased from 52.6% ‘always or sometimes’ to 22.2% one year after completing the training, with 47.4% reporting not using the tool immediately after the training and 74.1% one year after. The use of the tool had not become routine, and it was perceived as unnecessary to discuss the disclosure dilemma with clients. Furthermore, employment specialists reported that the content of the training rapidly became a lesser priority to other tasks and work activities.
Despite relatively low engagement, the tool led to some notable benefits:
- The intervention increased awareness of workplace stigma and the disclosure dilemma across both clients and employment specialists, 94% of clients found the tool useful and 87% of clients would recommend it to others.
- Just over half of clients indicated the tool had been helpful in their disclosure decision, becoming more aware of the pros and cons of both disclosure and non-disclosure; after 12 months none had disclosed at job application letter stage (baseline: 12%) and 19% had disclosed sometimes or always during a first job interview (baseline: 23%).
- RCT results showed that clients in the intervention group had found (51%) and retained (41%) paid employment twice as often compared to the control group (respectively 26% and 23%).
This feasibility study showed that decision-making tools like Conceal or Reveal can increase awareness of the pros and cons of both disclosure and non-disclosure when applying for jobs.
Conclusions
The authors concluded that the intervention was feasible to implement and was successful in increasing awareness of stigma and the disclosure dilemma in both clients and employment specialists.
Additionally, they demonstrated the importance of educating and motivating employment specialists in using tools and resources to discuss topics of stigma and disclosure with clients, and the need to embed systemically tools such as Conceal or Reveal.
This study shows the importance of motivating employment specialists to discuss topics of stigma and mental illness disclosure with clients.
Strengths and limitations
The strengths of this study included the use of the theoretical framework by Steckler and Linnan (2002), which provided a robust approach to assess many relevant process components. Further, the mixture of quantitative and qualitative data from the two target groups, clients and their workplace specialists was a benefit of this study.
Although the authors do not acknowledge it as a strength, the remuneration for clients’ participation in the study is a key strength of the study; the knowledge and expertise provided by people with lived experience in their engagement in anti-stigma interventions should be remunerated, just as their professional services are, particularly if they are unemployed. However, it is important to ensure any financial remuneration does not affect their rights to secure social benefits (Thornicroft et al., 2022).
The study is limited due to the exclusion of clients that did not speak Dutch. This lack of command of the language could be due to low language literacy or, most likely, because of non-native status. Women Engage for a Common Future report (page 3, 2019) sets out that “there is low unemployment overall in the Netherlands – 3.3% (down from 7.9% in 2014) but rates are higher or lower for different groups of workers/employees. People with a migrant background are more likely to be unemployed, and it is worse if they are from a non-western background.” This highlights the importance of co-creating interventions that are culturally appropriate (Arundell et al. 2021), along with taking an intersectional approach to reducing stigma. Indeed, our experiences cannot be universalised. There can be thematic similarities and shared experiences, but intersections produce unique experiences of stigma and discrimination, and the most marginalised experiences are often unintentionally overlooked, or intentionally ignored.
“Our experiences cannot be universalised. There can be thematic similarities and shared experiences, but intersections produce unique experiences of stigma and discrimination, and the most marginalised experiences are often unintentionally overlooked, or intentionally ignored.”
Implications for practice
This feasibility study highlights that implementation of a stigma awareness intervention in municipal practice could lead to double the employment rates of unemployed people with mental health problems without the need for a significant investment.
Key implications include:
- Systemically embedding anti-stigma awareness interventions in vocational rehabilitation services but other services beyond ‘employment’. This can help to understand intersectional mental health stigma as a barrier to disclosure and how best to support clients and service users to make informed decisions about when and how to disclosure their needs. Senior leaders and decision-makers in municipalities should consider this.
- Investing in workforce capacity building to upskill employees in key supporting roles to have the knowledge, skills, ability and confidence to have supportive and compassionate conversations with clients and service users around the disclosure dilemma, and challenge mental health stigma when and where they see it within the workplace.
- Ensuring training and learning provides opportunities for social contact; for example, by co-developing and co-delivering sessions with people with lived experience that include conversations about mental health stigma or including diverse lived experience videos where people share their experiences for participants to reflect on and discuss.
- Committing to effective evidence-based interventions like the mental health stigma awareness intervention described by the author, which can help municipalities improve work participation outcomes among unemployed people with mental health problems or illness and reduce unemployment working towards long-terms ambitions to close the employment gap and reduce impact on social benefits.
Simple and effective mental health stigma awareness interventions can reduce unemployment rates and, in turn, reduce reliance on social benefits.
Statement of interests
I have no competing interests to declare.
Links
Primary paper
Janssens, K. M. E., Joosen, M. C. W., Henderson, C., van Weeghel, J., & Brouwers, E. P. M. (2024). Improving work participation outcomes among unemployed people with mental health issues/mental illness: Feasibility of a stigma awareness intervention. Journal of Occupational Rehabilitation, 34(2), 447-460.
Other references
Arundell, L. L., Barnett, P., Buckman, J. E., Saunders, R., & Pilling, S. (2021). The effectiveness of adapted psychological interventions for people from ethnic minority groups: A systematic review and conceptual typology. Clinical psychology review, 88, 102063.
Cummins, I. If mental illness excludes us from the labour market, how can we make employment work for all? The Mental Elf, March 2023.
Deloitte, 2024. Mental health and employers: The case for employers to invest in supporting working parents and a mentally healthy workplace.
Henderson C, Brohan E, Clement S, Williams P, Lassman F, Schauman O, et al. Decision aid on disclosure of mental health status to an employer: feasibility and outcomes of a randomised controlled trial. Br J Psychiatry. 2013; 203(5):350–7.
Lagunes Cordoba, E. Reducing stigma and sickness absence: can a low intensity psychological intervention help us ‘Prevail’? The Mental Elf, November 2023.
Steckler AB, Linnan L, Israel B. Process evaluation for public health interventions and research. San Francisco: Jossey-Bass; 2002.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2019. Addressing Stigma: Towards a More Inclusive Health System – Canada.ca
Thornicroft, G. et al. The Lancet Commission on ending stigma and discrimination in mental health. The Lancet, Volume 400, Issue 10361, 1438 – 1480, 2022.
Van den Bossche, C. Inequalities in the Netherlands: Above average in the EU but there are worrying trends. Women Engage for a Common Future (WECF), 2019.
