Rebecca Iris Bogaers Stigma as a barrier to sustainable employment and well-being of workers with mental health issues and illnesses A mixed methods study in the Dutch military

Stigma as a barrier to sustainable employment and well-being of workers with mental health issues and illnesses A mixed methods study in the Dutch military Rebecca Iris Bogaers

Stigma as a barrier to sustainable employment and well-being of workers with mental health issues and illnesses The research described in this thesis was mainly funded by the IMPACT PhD Program 2018 of Tilburg University. Additionally, the research was partially supported by a grant from the Dutch Ministry of Defence. The author gratefully acknowledges financial support for the reproduction of this thesis by Tilburg University and by the Dutch Ministry of Defence (‘Duurzaam Gezond Inzetbaar (DGI)’ and ‘Expertisecentrum MGGZ’). Cover Iris Burgers Lay-out Ilse Modder – www.ilsemodder.nl Print Gildeprint Enschede – www.gildeprint.nl ISBN 978-94-6419-811-9 ©2023 Rebecca Iris Bogaers, The Netherlands. All rights reserved. No parts of this thesis may be reproduced, stored in a retrieval system or transmitted in any form or by any means without permission of the author. Alle rechten voorbehouden. Niets uit deze uitgave mag worden vermenigvuldigd, in enige vorm of op enige wijze, zonder voorafgaande schriftelijke toestemming van de auteur.

Stigma as a barrier to sustainable employment and well-being of workers with mental health issues and illnesses A mixed methods study in the Dutch military Proefschrift ter verkrijging van de graad van doctor aan Tilburg University op gezag van de rector magnificus, prof. dr. W.B.H.J. van de Donk, in het openbaar te verdedigen ten overstaan van een door het college voor promoties aangewezen commissie in de Aula van de Universiteit op vrijdag 23 juni 2023 om 13.30 uur door Rebecca Iris Bogaers, geboren te Eindhoven

Promotores: prof. dr. E.P.M. Brouwers (Tilburg University) prof. dr. J. van Weeghel (Tilburg University) Copromotor: dr. S.G. Geuze (UMC Utrecht) Leden promotiecommissie: prof. dr. Sir. S. Wessely (King’s College London) prof. dr. C. Freese (Tilburg University) prof. dr. K. Proper (Amsterdam UMC) prof. dr. S. Gürbüz (Tilburg University) dr. T. Wingelaar (Dutch Ministry of Defence)

CONTENT Chapter 1 General introduction Chapter 2 Barriers and facilitators for treatment-seeking for mental health conditions and substance misuse: multi-perspective focus group study within the military Chapter 3 Seeking treatment for mental illness and substance abuse: A crosssectional study on attitudes, beliefs, and needs of military personnel with and without mental illness Chapter 4 The Decision (not) to Disclose Mental Health Conditions or Substance Abuse in the Work Environment. A multi-perspective focus group study within the military. Chapter 5 Mental health issues and illness and substance use disorder (non-) disclosure to a supervisor: A cross-sectional study on beliefs, attitudes and needs of military personnel. Chapter 6 Workplace mental health disclosure, sustainable employability and wellbeing at work: a cross-sectional study among military personnel with mental illness. Chapter 7 General conclusions and discussion Chapter 8 Summary Chapter 9 Nederlandse samenvatting Chapter 10 Dankwoord About the author Over de auteur List of publications 9 27 47 77 99 125 153 177 191 205 206 210 211 212

Chapter 1 General introduction

10 CHAPTER 1 1 GENERAL INTRODUCTION Mental health issues and illnesses (MHI), including substance use disorders, are very common. Globally, the lifetime prevalence of mental illness has been estimated to be 29% (1). A recent study in the Netherlands showed that the lifetime prevalence of mental illness has increased to 48% (2). At any given moment, approximately 20% of the working-age population experiences a mental illness (3). These numbers don’t even include stress-related mental health issues, such as burnout, which are common in the work setting, and responsible for a large share of sick leave. A recent survey among Dutch employees showed that about 1.3 million employees suffered from burnout complaints and that 37% of the employees on sick leave indicated stress-related issues as the main reason for their absence (4). As compared to workers without MHI, workers with these health problems have a significantly higher risk for sick leave, early retirement, exiting the workforce via disability benefits, or unemployment (5, 6). However, people with MHI can benefit from the positive aspects of employment, such as social participation and inclusion (7, 8). In previous research, job loss has been shown to lead to decreased health, while reemployment after unemployment has been shown to lead to increased health (9-11). This highlights the importance of investing in sustainable employment and well-being at work of workers with MHI. Additionally, due to the aging working population in Western countries, the current shortage of workers in many industries is likely to increase further in the coming decades (12, 13). This makes the topic of how society and especially employers can support sustainable employment of employees with MHI, a top priority. Stigma as a barrier to sustainable employment and well-being at work An important barrier to sustainable employment and well-being at work for workers with MHI is mental health stigma (9, 14). Many people with MHI describe stigma as even ‘worse than the condition itself’ (15). Under the influence of the previously dominant biomedical paradigm, it was assumed that people with disabilities do not participate optimally in the workforce primarily because of their disease, and consequently, the important role of non-disease-related factors (16), such as stigma, have been underresearched. The word stigma originates from the Greek language and means burn. It refers to specific people, for example, slaves or criminals, being branded to show others that this person was of lower status (17). A theory on stigma by Link and Phelan (18) proposes that ‘stigma exists when elements of labeling, stereotyping, separation, status loss, and discrimination occur together in a power situation that allows them’. According to this theory, the stigma process is made up of four different components: (1) Distinguishing

11 1 GENERAL INTRODUCTION and labeling human differences, (2) associating these labels with negative attributes, (3) separating ‘us’ from ‘them’, and (4) status loss and discrimination experienced by the labeled person (18). Another theory of stigma and discrimination by Thornicroft et al. (19) proposes that stigma refers to problems of knowledge (ignorance), attitudes (prejudice), and behavior (discrimination) (figure 1). This theory indicates that stigma starts with a lack of accurate knowledge about MHI. This lack of knowledge can lead to certain attitudes about people with MHI, which are often prejudices. Consequently, these attitudes can lead to behavior, namely discrimination against those with MHI. Figure 1. Stigma and discrimination theory by Thornicroft et al. (19). Mental health stigma exists at different levels. 1) Public stigma: members of the general population endorse prejudice and discrimination against individuals with MHI (20), 2) Selfstigma: this occurs when individuals with MHI internalize these negative stereotypes and prejudices held by the general population (21), and 3) Structural stigma/discrimination: this refers to rules, regulations, and cultural attitudes and values that either intentionally or unintentionally disadvantage individuals with MHI (22). This thesis will include all these different levels of stigma. Another form of stigma, which will not be further discussed in this thesis, is stigma by association, a process through which the companions of stigmatized persons are also discredited (23). Additionally, a distinction can be made between anticipated and experienced stigma, and this thesis will focus on both these types of stigma (24). Anticipated stigma refers to the stigma that people with MHI expect to occur. This may cause the ‘Why try’ effect, which refers to a situation where people refrain from certain behavior, such as applying for a job, because they anticipate stigma to occur (25). Experienced stigma refers to the stigma-related events that have actually occurred, such as being denied employment (26). Furthermore, stigma can occur in different life domains, but research has shown that the work context is a domain in which stigma and discrimination occur most frequently (27).

12 CHAPTER 1 1 Previous research has suggested that stigma forms a barrier to sustainable employment and well-being at work in four different ways, which can be seen in figure 2 (9). First, employers often hold negative (stigmatizing) attitudes towards workers with MHI, which can negatively affect supportive supervisor behavior (9, 28, 29). Second, both the disclosure and non-disclosure of MHI in the work environment can lead to job loss (9). Due to the fear of being stigmatized, many workers with MHI do not disclose this in their work environment (30). However, disclosure can be important for the prevention of adverse occupational outcomes, such as sick leave and job loss, as it can lead to work adjustment and supervisor support (31). Disclosure can thus prevent adverse occupational outcomes through work adjustments and supervisor support, but simultaneously disclosure can lead to stigma and discrimination. Third, self-stigma, and the ‘Why Try’ effect can lead to a lack of motivation and effort to keep employment (9). Fourth, stigma is a barrier to treatment-seeking, which can lead to untreated and worsened symptoms, which can negatively influence sustainable employment and wellbeing at work (9, 32). The focus of the current thesis will be on the second (disclosure) and fourth (treatment-seeking) problem areas. Figure 2. Four key problem areas of stigma for sustainable employment of people with mental health issues and illnesses (9). Mental health stigma in the military Military personnel operate in potentially hazardous, dangerous, and emotionally demanding situations (33). Being exposed to stressors at work can lead to an increased risk of developing MHI – including posttraumatic stress disorder, substance use

13 1 GENERAL INTRODUCTION disorders, and depressive symptoms (34, 35). It should be noted that military personnel do not necessarily experience more MHI compared to civilians. The prevalence of MHI among military personnel differs between countries, and there are mixed findings when comparing the prevalence of MHI among civilians and military personnel. Some studies found that military personnel experienced less MHI compared to civilians (36), some showed that military personnel experienced more MHI compared to civilians (37, 38), and some found a similar prevalence among military personnel and civilians (36). The mental health stigma can be expected to be even stronger in the military, compared to civilian populations. For example, a study in the Canadian army showed that military personnel were 1.7 times more likely to have perceived stigma compared to a civilian sample (39). This is likely caused by the military culture. In the military, there is a general focus on being strong and tough, which enhances the negative opinions about those who have a MHI, as they might not be able to do the same tasks as they were once able to do (40, 41). Mental health stigma can influence two important decisions that military personnel with MHI face, namely (1) the decision to seek treatment (42) and (2) the decision to disclose a MHI to a supervisor (43). Both these decisions can affect health, sustainable employment, and well-being at work (see figure 2) (9, 14, 43, 44). Therefore, the current thesis will focus on these two decisions within the military context. The decision to seek treatment Worldwide, there is a treatment gap for MHI, which means that there is a mismatch between the proportion of people who could benefit from treatment and those who seek treatment (45). This is partly caused by (affordable) treatment not being available, but also because people do not seek treatment (46). Especially in high-risk occupations, such as the military, workers find it difficult to seek treatment (9, 47, 48). A recent systematic review showed that about 60% of military personnel who experienced MHI did not seek help, whereas many could benefit from professional treatment (49). Leaving MHI untreated poses a threat to sustainable employment through a higher risk of sick leave and unemployment (5, 9). Besides negative consequences that affect well-being at an individual level, there are high economic and social costs involved when leaving these conditions untreated (4, 50).The international literature reports different factors that determine whether military personnel seek treatment or not. They are related to (1) stigma and discrimination, (2) sociodemographic factors, (3) characteristics of the healthcare environment, and (4) treatment and MHI beliefs. All four factors will be considered in the present thesis.

14 CHAPTER 1 1 Stigma and discrimination Many studies identified concerns related to stigma and discrimination as barriers to treatment-seeking (48). One of the most reported concerns was the concern that seeking treatment harms one’s military career. Additionally, military personnel were concerned that treatment-seeking would result in blame, differential treatment, and less confidence in their ability from supervisors and peers (51-54). Sociodemographic factors This includes factors like sex, age, marital status, rank, and severity of MHI. For example, previous research showed that females were more likely to seek treatment than males (55-58) and that more senior ranks were less likely to seek treatment than lower ranks (55, 56). Characteristics of the health care environment Previous research reported several structural and logistical barriers to treatmentseeking. For example, difficulties scheduling appointments and getting time off work formed barriers to treatment-seeking (51, 53, 54). There were fewer concerns about the availability and costs of treatment, as military personnel in most countries have military health care benefits (57). There were also concerns about the confidentiality of consulting a mental health professional, which might be due to mental health stigma (58). Treatment and MHI beliefs Some military personnel reported that they believed that treatment is not effective. Negative attitudes towards treatment were associated with lower interest to receive treatment (56). Additionally, military personnel showed a big preference to solve problems on their own, instead of seeking treatment. This is referred to as the preference for self-management (58-62). The literature also discusses several key facilitators for treatment-seeking in the military. Social support, unit cohesion, and positive leadership were found to be key facilitators for treatment-seeking. For example, encouragement and support from a partner, family, and friends were associated with military personnel being more prone to seek treatment (52, 54, 63). Additionally, unit cohesion and positive leadership behavior were associated with lower reported barriers to care (20, 64). An important model often used to explain planned behavioral intentions, including health-related behavior such as treatment-seeking (65, 66), is the theory of planned behavior (figure 3). According to this theory, planned behavior is influenced by (1) individuals’ attitudes toward the behavior, (2) subjective norms, and (3) individuals’

15 1 GENERAL INTRODUCTION perceived behavioral control (67). The theory has been used before to examine MHI treatment-seeking (68), also in a military setting (67, 69, 70). The current thesis aims to gain insight into the decision to seek treatment, and the different factors that are of influence on this decision, such as (but not limited to) attitudes, subjective norms, and behavioral control. The aim is not to test the theory of planned behavior. Figure 3. Theory of planned behavior (65). Although there is international literature on barriers and facilitators for treatmentseeking for MHI in the military, research on this topic was completely lacking within the Dutch military. To implement effective interventions to promote treatment-seeking, and subsequently sustainable employment and well-being at work, it was important to first examine the decision to seek treatment for MHI within the Dutch military context. The decision to disclose mental health issues and illnesses to a supervisor The decision to disclose MHI to a supervisor or not can potentially impact sustainable employment and well-being at work (9, 14, 43, 44). Previous research has shown that disclosure to a supervisor can lead to work accommodations and supervisor support, which can prevent worsened symptoms and sick leave, and non-disclosure can lead to missed opportunities for this support (43, 44, 71). However, disclosure can also lead to being stigmatized and discriminated against, which can negatively affect sustainable employment and well-being at work (72, 73). Additionally, disclosure can decrease the chances of getting promoted in the future (28, 74, 75). This makes the decision to disclose MHI to a supervisor or not, a true dilemma. Compared to the literature on treatment-seeking in the military, the literature on disclosure to a supervisor in the military is extremely scarce. There has been some work

16 CHAPTER 1 1 on disclosure to family and friends in the military (76), but not on disclosure in the workplace. To our knowledge, this has only been directly examined within the German military, with a qualitative study examining attitudes toward disclosure among German soldiers and their comrades (73). This study showed that common negative stereotypes about soldiers with MHI were weakness and incompetence and that disclosing MHI was expected to lead to gossip, discrimination, and negative career consequences (73). Although research on disclosure to a supervisor was almost completely lacking within the military, there has been more research on the disclosure of MHI in civilian workplace settings, and therefore this literature will now be discussed. Toth and Dewa (77) proposed a model of employee decision-making about the disclosure of MHI at work, see figure 4. According to this model, employees begin from a default position of non-disclosure of MHI. This default position of non-disclosure is caused by three factors; (1) fear of stigmatization, (2) employees wanting to maintain boundaries in the workplace, especially between work and home lives, and (3) employees wishing to maintain confidentiality. According to the model, a triggering incident is needed, before employees start to assess the risks and benefits of disclosure and make a disclosure decision. Research has shown that this decision was often purely driven by consideration of negative aspects of disclosure – neglecting the potential positive aspects such as (temporary) work adjustments (78). While the model proposes a default position of non-disclosure, recent research among Dutch employees suggests that there might not be a default of non-disclosure in the Netherlands. Of those with MHI, 73% indicated that they had disclosed their MHI to their supervisor (29), and of those without MHI, 75% indicated that they would disclose to their supervisor if they would develop MHI in the future (79). Participants indicated that important reasons to disclose their MHI were the responsibility belonging to their job and that they ‘did not want to hide’ (29). Figure 4. Model of employee decision-making about disclosure of a mental disorder at work (77).

17 1 GENERAL INTRODUCTION A recent interdisciplinary review (80) of the literature on the disclosure of MHI in the workplace provides additional insight into antecedents to the (non-)disclosure decision and outcomes of disclosure. This review proposed that important internal antecedents of non-disclosure are stigma-related. For example, as workers had the fear of being treated differently, they concealed their MHI (79, 81-83). Furthermore, other internal antecedents to disclosure included attitudes towards disclosure (81), self-management capabilities (84), disclosure motives (e.g. to arrange for work accommodations) (85), perceived organizational support (86, 87), and symptomatology (both severity of symptoms and variations in diagnosis) (88). The review also discussed external antecedents to disclosure (80), and these external antecedents highlighted the importance of the supervisor for the disclosure decision. Supervisors’ attitude (89), personality (90), competencies (91), and social support (90) were all antecedents to disclosure. Furthermore, organizational support (86) through a supportive climate was also an important antecedent to disclosure. Finally, the interdisciplinary review (80) also discussed several important outcomes of disclosure. First, stigma and discrimination are possible outcomes of disclosure. Research has shown that disclosure can result in negative reactions from colleagues and supervisors. For example, being treated differently, being gossiped about, and being labeled as weak and less competent (73, 82). Second, disclosure can negatively affect employment outcomes through job loss and discrimination (78, 92-94). However, several studies have also found positive effects of disclosure on employment outcomes, as it allows people to continue working through work adjustments and social support (81, 92, 95, 96). Third, disclosure can also have other positive outcomes on a group level, as it can create a culture of disclosure that can encourage other workers with MHI to disclose (97). Also, it can lead to increased psychological well-being, as workers often felt more accepted after disclosure and had feelings of relief over time (98). These mixed positive and negative outcomes of disclosure can make the disclosure decision difficult. This disclosure dilemma is expected to be even more prominent for trauma-prone occupations, such as the military, where workers are expected to be ‘strong’ and disclosure may yield less positive outcomes (47, 99). However, as research on supervisor disclosure in the military is very scarce (73), more research is needed into the (non-) disclosure decision in the military, as these insights can help to facilitate disclosure in a safe environment so that personnel can receive support which can prevent adverse occupational outcomes (43, 44, 71). Additionally, as disclosure can negatively and positively affect sustainable employment and well-being at work, more insight is needed into the direct association between disclosure and sustainable employment and wellbeing at work.

18 CHAPTER 1 1 Sustainable employment and well-being at work In the literature, there are different conceptualizations of sustainable employment, as it is a broad concept that is hard to grasp (100-102). Generally, sustainable employment refers to the ability of workers to participate in the labor market during their lifetime (103). Traditionally sustainable employment focuses more on performance indicators, such as workability (104), and medical indicators such as sick leave (105). However, due to the emerging field of positive organizational psychology (106), there is now more focus on well-being at work. A more recent conceptualization of sustainable employment, based on the capability approach and which includes well-being at work, has been proposed by van der Klink et al., namely ‘throughout their working lives, workers can achieve tangible opportunities in the form of a set of capabilities. They also enjoy the necessary conditions that allow them to make a valuable contribution through their work, now and in the future, while safeguarding their health and welfare. This requires, on the one hand, a work context that facilitates this for them and on the other, the attitude and motivation to exploit these opportunities’ (103). An important aspect of this conceptualization is the set of capabilities that workers can develop if they are able and empowered to realize their work values as meaningful goals in the work context (103, 107). Examples of work values are ‘using your knowledge and skills in your work’ and ‘being involved in important decisions about your work’. According to this capability approach, for employees to have high levels of sustainable employment, they should (a) consider certain work values as important, (b) have adequate work opportunities to achieve these values, and (c) be personally able to realize them (103, 107). If this is the case, a work value is part of someone’s set of capabilities. According to this conceptualization, the value of work is an important aspect of well-being at work, and thus of sustainable employment (103). The current thesis will include both the traditional perspective on sustainable employment, focusing on performance, and more novel indicators of sustainable employment, such as well-being at work. The context of this thesis The research presented in this thesis was conducted within the Dutch military. The Dutch military is a military force with approximately 40.000 military personnel and no compulsory military service. For the interpretation of the results of this thesis, it is important to elaborate on the structure of mental health care and the legislation related to substance (ab)use in the Dutch military.

19 1 GENERAL INTRODUCTION In the Dutch military, all healthcare is organized internally. This includes mental health treatment. There are four mental healthcare treatment centers distributed across the Netherlands, which means that there is always treatment available relatively close to someone’s home. Military personnel can seek treatment for both MHI and substance use disorders, and the costs are covered by military health insurance. For ‘soft drugs’ (such as marijuana, hashish, and sleeping pills) and alcohol, treatment is provided within the military, for ‘hard drugs’ (such as heroin, cocaine, and amphetamine) military personnel is referred externally. Military personnel can also individually decide to seek treatment outside of the military; however, they should first gain permission from their health insurance to ensure these costs will be covered. Regarding the rules and legislation concerning substance use, there is a zero-tolerance policy for use of hard drugs within the military, with the sanction of unconditional discharge. The use of alcohol is only forbidden during training and deployment. The use of soft drugs results in an official warning from the military, with multiple warnings leading to discharge. However, when substance use is reported to a mental health professional, there are confidentiality agreements that ensure privacy, and treatment is possible. When military personnel seek treatment, their treatment and diagnosis are not reported to their supervisor. They can decide for themselves whether they tell the supervisor about their MHI, or substance use disorder. However, there is an exception if the patient forms a risk for their safety or the safety of their immediate surrounding, then the supervisor will be informed. Finally, it should be noted that the current thesis examines mental health issues and illnesses. This includes diagnosed mental health illnesses, but also self-reported (undiagnosed) mental health issues, such as stress-related issues. These mental health issues and illnesses also include substance use disorders. The present thesis This thesis has three main aims: 1. To gain insight into the decision of whether or not to seek treatment for MHI within the Dutch military, and to which extent stigma plays a role in this decision. 2. To gain insight into the decision of whether or not to disclose MHI to a supervisor in the Dutch military, and to which extent stigma plays a role in this decision. 3. To gain insight into the association between actual disclosure decisions and disclosure experiences, and subsequent sustainable employment and well-being at work in the Dutch military.

20 CHAPTER 1 1 Therefore, this thesis will be divided into the following chapters. Chapter 1 provides a general introduction to the topics of the thesis. This is followed by two chapters about treatment-seeking for MHI in the military. Chapter 2 discusses a qualitative focus group study on treatment-seeking. This study examined the barriers to and facilitators for treatment-seeking, from multiple perspectives – military personnel with and without MHI and mental health professionals. Following, Chapter 3 discusses a quantitative questionnaire study on treatment-seeking in the military. This study examined the attitudes, beliefs, and needs of military personnel with and without MHI regarding treatment-seeking. The next chapters are about the disclosure of MHI to a supervisor in the military. Chapter 4 consists of a qualitative focus group study on disclosure. This study examined barriers to and facilitators for disclosure from multiple perspectives – military personnel with and without MHI and mental health professionals. This is followed by Chapter 5, a quantitative questionnaire study on disclosure. This study examined the attitudes, beliefs, and needs of military personnel with and without MHI regarding disclosure to a supervisor. Chapter 6 will provide insight into disclosure, sustainable employment, and well-being at work. Specifically, it will discuss a quantitative questionnaire study that examined disclosure decisions, disclosure experiences, and their association with several measures of sustainable employment and well-being at work. Finally, Chapter 7 will consist of a general discussion of the findings of this thesis and place them in a broader context. Strengths and limitations will be discussed, together with implications for practice, implications for policy, and recommendations for future research.

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