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Photo by Kham/Reuters


The last great stigma

Workers with mental illness experience discrimination that would be unthinkable for other health issues. Can this change?

by Pernille Yilmam + BIO

Photo by Kham/Reuters

It is not difficult to find stories about the burdens and barriers faced by employees or job-seekers with mental illness. For example, it was recently reported that Scotland’s police denied a position to a promising trainee because of her use of antidepressants – in keeping with a rule that officers must be without antidepressant treatment for at least two years. In other cases, people have reported being fired from jobs at a university, a nursing home facility, a radio station, and a state agency following requests for medical leave due to postpartum depression, anxiety, depression and bipolar disorder, respectively. A US government commission maintains a select list of resolved lawsuits against companies that involved claims of mistreatment based on a worker’s mental health condition.

Often, the impact of negative attitudes toward mental illness is less overt than in these examples. More than a decade ago, a university professor named Suzanne published a book in which she openly discussed her life with bipolar disorder. The personal details that she revealed in the book, she told me, became a foundation for discriminatory treatment at her workplace. She said she experienced professional isolation in the hallways and meeting rooms: that colleagues stopped inviting her to collaborate with them, that she was shut down in department meetings and cut off from participating in decision-making committees. She attributes these developments to knowledge of her mental illness.

‘I experienced a very noticeable chill, averted eyes, actually being cut off when speaking in meetings,’ Suzanne recalled. ‘Lots of loaded language, of the “Well, SOME people just need to take their meds” variety, in meetings. This was the stage of my professional career where I started calling myself “the crazy lady in the corner”.’ At one point, when she had to take medical leave to address symptoms associated with her condition, a colleague opined that she was ‘lucky’ to have the option.

In light of such stories, it’s not surprising that concerns about revealing mental health problems at work are commonplace. It’s estimated that 15 per cent of working-age adults have a mental health condition, and in a 2021 survey in the US, three-quarters of workers reported one or more symptoms of mental illness. One study surveying more than 800 people with major depressive disorder worldwide found that between 30 and 45 per cent reported experiencing discrimination in the workplace, with people in high-income countries reporting it at higher rates. A third of US employees polled by the American Psychiatric Association said they were worried about the consequences at work if they sought help for their mental health condition. In England, 61 per cent of survey respondents who were severely affected by mental illness said that ‘the fear of being stigmatised or discriminated against’ stopped them from applying for jobs and promotions. While there are signs that stigma related to mental illness has decreased over time (at least in some countries), stigma and discrimination continue to pose a problem in many workplaces.

Since the 1990s, a number of laws around the world have prohibited discrimination against employees with physical and mental disabilities. Among these are the Americans with Disabilities Act of 1990 in the US, the Disability Discrimination Act 1992 in Australia, and Article 13 of the Amsterdam Treaty of 1997 in the European Union. While these laws have done much to advance protections for people with disabilities, their impact on the treatment of people with mental illness – which constitutes a form of disability for many – has clearly had limits.

Mental illness-related discrimination persists as a multilayered problem characterised by fear, misconceptions and underenforced laws. The encouraging news is that scientists have been developing interventions to help reduce stigma and discrimination related to mental illness – approaches that should receive much more attention if advocates, employers and governments want to make workplaces fairer for all.

Job seekers reluctant to mention a mental illness history were more likely to be employed six months later

Discrimination against people with mental illness is often rooted in preconceived notions about what mental illness is and how it affects someone’s ability to work. These negative misconceptions are forms of mental illness stigma. Research has found that stigma is sometimes expressed by employers and colleagues as an issue of trust: eg, a belief that people with mental illness need more supervision, that they lack initiative, or that they are unable to deal with clients directly. Some might believe that people with mental illness are dangerous, or that they should hold only manual, lower-paying jobs. Research also suggests that many employers and coworkers believe people with mental illness should participate in the workforce, but are reluctant to work with them directly – which has been described as a type of ‘not in my backyard’ phenomenon.

Discriminatory behaviours have been investigated as well. In the US, researchers found that fictitious job applications that mentioned an applicant’s hospitalisation for mental illness led to fewer callbacks than applications noting a hospitalisation for a physical injury. Similar results were observed in Norway. In Germany, scientists found that job seekers who were more reluctant to mention their mental illness history in applications and interviews were more likely to be employed six months later. In addition to the potential impact on hiring, some people with mental illness have told researchers they believe they have been refused a promotion due to their condition.

In one revealing study, Matthew Ridley, an economist at Warwick University in the UK, had pairs of strangers collaborate on a virtual task. Before the task, each participant was shown characteristics of the person they had been matched with, which in some cases included mental illness. Ridley then asked if they wanted to be paired with someone else instead. The participants, he found, tended to be willing to give up some of their anticipated financial compensation to avoid working with a person who had significant depression or anxiety symptoms. When asked why, they indicated that they thought people with a mental illness would be less efficient in completing the task, would require more support, and would be less fun to work with. (For their part, among the participants who revealed to Ridley that they had a mental illness, a majority said they would pay to not have that fact revealed to their partner.)

In the end, participants were paired randomly and, when Ridley analysed the results, he found no differences in task success or enjoyment, regardless of whether someone worked with a person who had a mental illness. The findings capture how negative assumptions can come into play – and prove to be inaccurate – even in the context of a temporary collaboration.

The perpetuation of mental illness stigma and discrimination comes at a cost not only to the affected individual, but also to companies and societies. The World Health Organization (WHO) estimates that mental illness costs the global economy $1 trillion annually. Among the reasons for these astronomical costs are the higher rates of sick days and unemployment among people with mental illness. The increased absences are partly due to lack of access to treatment; in 2021, it was estimated that only half of all US adults with mental illness had received mental health services in the past year. But a potential aggravating factor is that some employees with mental illness refrain from using their work-associated health insurance for treatment, out of fear that their employer will learn about their condition, resulting in their dismissal, or other forms of discrimination.

The denial of reasonable workplace accommodations could also make a person’s job more difficult and absences more likely. For a person who uses a wheelchair, an accommodation might be a ramp where there are stairs; for a person with a mental health condition, such as an anxiety disorder or ADHD, it could mean having a private office or noise-cancelling headphones to help with concentration problems, or flexibility in one’s work hours in order to attend healthcare appointments or accommodate heightened symptoms. It could also mean requesting leave for a mental health condition – up to 12 weeks in the US, similar to medical leave for physical injuries or for sickness. But some employees might avoid requesting the accommodations they are legally allowed to receive, simply because they suspect that doing so puts their job security and potential for advancement at risk.

The greater amount of absences among people with mental illness can make firings more likely. Losing a job can worsen mental illness, and people often stop applying for new jobs because they anticipate stigma and discrimination.

A list of the top 10 disabilities in US discrimination claims included depression, anxiety disorder and PTSD

Of course, one’s experience of work itself – a major cause of stress for many people – can also contribute to mental illness. One woman I spoke with, whom I’ll call Sara, shared that unsupportive and hostile work environments have made her anxiety even worse than it used to be. She believes that having to take time off work for her mental health led to her sudden termination from her previous job.

Under the Americans with Disabilities Act (ADA), US employers are legally prohibited from discriminating based on physical or mental disabilities at any point during hiring, firing or professional evaluation. The same is true in Australia, based on the Disability Discrimination Act. Other countries have passed antidiscrimination legislation since then too, including South Africa’s Mental Health Care Act 17 of 2002 and India’s Equality Bill, 2019.

Yet, as we’ve seen, decades after the implementation of the ADA, problems remain. Studies continue to document stigma and discrimination against workers with mental illness. In 2020, a list of the top 10 disabilities in US discrimination claims included depression, anxiety disorder and PTSD. In Australia, a commission concluded back in 2004 that the country’s antidiscrimination legislation had been less effective in helping people with mental illness than those with mobility and sensory disabilities. In the EU, where Article 13 of the Amsterdam Treaty created a binding agreement to illegalise discrimination based on disabilities, researchers and clinical professionals were quick to point out its vagueness and lack of defined scope. An EU-funded consensus paper from 2010 documented the continued problem of discrimination against employees and job-seekers with mental illness.

Reports such as these call into question whether even a major law like the ADA can adequately address discrimination related to employee mental illness. And they should prompt us to reconsider how best to combat the problem. One question we can ask is: what might limit the impact of such laws in curbing discrimination against people with mental illness, compared with discrimination against people with physical disabilities? Let’s consider three potential answers.

First, discriminatory behaviour is not always obvious, and sometimes it is not even intentional. Compared with an employee who uses a wheelchair, it might be easier to dismiss a socially anxious person’s need to work from home. Compared with someone who is getting treatment for cancer, it might be easier to question whether an employee newly diagnosed with bipolar disorder will ever return as a valuable employee after their medical leave. Compared with a trauma-induced concussion, it might be easier to wonder whether a hypersensitivity to noise, related to PTSD, is really legitimate. Mental illnesses and their effects on people’s daily lives are often less apparent to others than the effects of a physical disability.

Second, laws like the ADA work only if people open up about their disabilities. The physical disability community has in the past decades led a cultural shift from exclusion and shame toward inclusivity and empowerment. People with physical disabilities have community, speak up and exercise their rights. Although there are ongoing efforts by people with mental illness to raise awareness about their experiences, many individuals stay quiet due to shame about their own condition or fear of how others will respond.

Even employers who want to hire people with mental illness can be subject to misguided beliefs

Lastly, the public stigma against mental illness bleeds into what people are expected to be able to handle and achieve. While physical disability is commonly perceived as a challenge with movement, mental illness is perceived as a challenge with thinking. Physical disabilities are seen as being caused by accidents or other unfortunate circumstances, while mental illnesses are often incorrectly seen as a choice or an inherent character flaw. Other misconceptions are that mental illness generally is untreatable or renders people violent or unable to work. An employer might therefore deem a person with mental illness unable to meet their job responsibilities, even when this assumption is unfounded.

Antidiscrimination laws are important, but they do not eliminate the tolls of stigma and capitalism. Employers want to make money, and a mental illness can be seen as a financial liability. Even employers who say they want to hire people with mental illness can be subject to misguided beliefs. And even when companies do grant accommodations, they might be limited. Sara, who in addition to struggling with anxiety has long had difficulty with focusing in distracting environments, was recently diagnosed with ADHD. Together with her psychiatrist, she submitted a request to her large corporate employer to work from home on two weekdays of her choosing, which would enable her to better focus on computer tasks – something that for her is much more difficult in a distracting open-office environment. She told me that it took six months for the accommodation request to be processed; in the end, she was allowed to work from home only on Mondays.

If people can develop the compassion needed to understand why ramps should be installed for use by employees with wheelchairs, there must be a way to heighten compassion for those who would benefit from, for example, a less distracting work environment. But history suggests it won’t be enough to make discriminatory practices illegal. It will require a change in perceptions.

For many employees or job candidates with a mental illness, the prospect of workplaces free of stigma and discrimination may seem unattainable. ‘I cannot say anything definite that helps [reduce discrimination],’ Suzanne tells me. ‘If you keep your head down and do your job, then good people will eventually accept that this person is still fulfilling their job.’ There are, however, scientifically supported strategies that could be used in efforts to reduce mental illness stigma – and, consequently, discrimination – in workplaces. To the frustration of many anti-stigma advocates, these strategies have not yet been widely implemented.

One basic stigma-reducing strategy is based on social contact. Research suggests that people who have regularly interacted with someone who has personal experience with mental illness (such as a family member, friend or colleague) are often less likely to stigmatise and discriminate, and may be more likely to engage in empathic conversations about mental illness with employees. A law like the ADA should in theory have facilitated more social contact: if it freed more employees to disclose their mental illness and ask for reasonable accommodations, their coworkers would have learned that someone can have a mental illness and still be smart and productive. But, again, many people still do not disclose their mental illness (for fear of discrimination or other reasons), and coworkers cannot learn from what is not disclosed.

Educating HR professionals about mental illness could help reduce discriminatory practices

Another promising method for improving attitudes and behaviour toward employees with mental illness is psychoeducation. Broadly speaking, psychoeducation, also known as mental health education or mental health literacy, is a method of teaching what mental health is, why people might develop mental illnesses, and how these illnesses can be prevented and treated. It can also include the sharing of actionable strategies for coping with symptoms and crises, both acutely and preventatively. Psychoeducation incorporates components of group therapy and cognitive behavioural therapy, and is frequently used by psychiatrists and therapists in clinical settings. It was originally developed to support patients with severe mental illnesses, such as schizophrenia or bipolar disorder, and their families.

Excitingly, psychoeducation can also be used to help change the way workers with mental illness are perceived. While it has been most studied among patient groups as a method to reduce symptom severity and increase healthy coping strategies, it has been employed in professional settings too. For example, a systematic review of studies indicated that psychoeducational training for managers can improve their ‘knowledge, attitudes and self-reported behaviour in supporting employees experiencing mental health problems’. One study reported that managers who received psychoeducational training felt more confident in talking with employees about mental illness and were more likely to reach out to an employee who had an extended absence due to mental illness or stress. Researchers have also suggested that educating human-resources professionals about mental illness could help reduce discriminatory practices. Recently, the implementation of psychoeducational programmes in six companies within high-stress industries (such as hospitality) was found to reduce ratings of stress among workers and mental illness stigmatisation among workers.

The results from these studies are encouraging. Because psychoeducation can be delivered virtually in group settings and can be led by non-experts who’ve received appropriate training, it is also a cost-effective, scalable method. (Full disclosure: last year, I founded a nonprofit that has started to offer psychoeducational services in schools and other organisations.) But, for now, this approach appears to be rarely deployed in workplaces outside of research studies.

The psychoeducation programmes in these studies typically take place in weekly, one- to two-hour sessions, lasting from a few weeks to months, and they are most often led by mental health professionals. They tend to focus on teaching people about and facilitating conversations on the causes, types, presentation and treatments of mental illness. The programmes often spend a considerable amount of time debunking common myths about mental health, and provide exercises to enable participants to help themselves or others with a mental illness. These exercises might include cognitive-behavioural tools for ‘fact-checking’ thought patterns, problem-solving skills, daily mood journals, and breathing exercises. A major goal is to challenge ideas about mental illness that underlie stigma and discrimination.

In a 2022 policy brief on mental health at work, the WHO argued for greater efforts to improve mental health literacy and support employees with mental illness. Psychoeducational programmes could be a prime tool for pursuing these goals, a staple for companies that aim to comply with antidiscrimination law and improve employee wellbeing. If psychoeducation helps key stakeholders, such as employers and human-resources professionals, to treat employees and job candidates with greater understanding, that might also lead to fewer sick days, enhanced productivity and more employment among people with mental illness. Perhaps work itself will become a less prominent driver of stress.

Some companies currently provide offerings such as unlimited vacation days, meditation apps or yoga sessions as a way to show support for employees’ wellbeing. But these sorts of benefits likely do little to address stigma or discrimination in workplaces. Moreover, implicit in this strategy is the idea that mental illness is a problem that can and should be addressed by individual employees, without putting broader workplace conventions and beliefs into question.

‘In contrast to my mental illness, my concussion was immediately accommodated’

While a severe version of a state such as psychosis or mania can be devastating for the person experiencing it, most people who have a mental health condition are not dealing with crises from day to day. Yes, someone with mental illness might be more easily distracted, more sensitive to noise or less social, but that doesn’t mean that their symptoms will inevitably hamper their job performance. What does hamper performance is when companies neglect to provide reasonable accommodations, even when studies suggest that the benefits associated with providing such accommodations outweigh the costs.

Wouldn’t most companies be inclined to provide structural and logistical support for an employee who suddenly became paraplegic, or who suffered another disabling physical ailment? One former tech industry employee told me that she saw a marked difference in how her leave-taking was received depending on whether it was mental health-related or not. ‘A while after returning from my mental health leave,’ she says, ‘I got a concussion for which I needed partial leave. The symptoms I had were so similar to my PTSD but, in contrast to my mental illness, my concussion was immediately accommodated with a 90-day medical leave and temporary part-time work schedule without any stigma.’ Sara, too, noticed a stark difference when she needed medical leave and other task-related accommodations to recover from shoulder surgery, as opposed to accommodations related to her mental health.

The evidence of ongoing and unnecessary burdens on workers with mental illness calls for honest consideration of what previous antidiscrimination measures have and have not achieved. Employers and governments have yet to fulfil the promise of landmark antidiscrimination laws for the many millions of people who go to work with mental health conditions. Fortunately, there is hope that evidence-backed approaches such as psychoeducational programmes could – if more widely embraced – provide an effective tool for making workplaces fairer and more supportive.