Forensic service users may face double stigma due to severe mental illness and a history of criminal offending. Professional stigma, involving stigmatizing attitudes and behaviors among mental healthcare professionals, can impede treatment and rehabilitation. Research on professional stigma, particularly toward forensic service users, is scarce. We explore relevant concepts of professional stigma using a Delphi consensus study and focus group. The Delphi study involved 98 experts across five panels (academics publishing about stigma or forensic mental healthcare, forensic and community mental healthcare professionals, and forensic service users), who evaluated the relevance of 85 stigma-related items on a 7-point Likert-scale. Consensus was reached on 26 items, including stereotypes, prejudices, and discrimination, reflecting dangerousness, fear, recovery potential, and restrictions. The focus group, involving seven forensic service users, yielded experiences with professional stigma, including recovery pessimism, perceived dangerousness, devaluation through offenses, dismissive reactions, differential treatment, intrusive behavior, and restrictions. Our findings highlight the complexity of conceptualizing professional stigma and provide a foundation for developing an instrument to assess it. Future research will evaluate the psychometric properties of this instrument, which is essential for identifying and addressing stigma in forensic and community mental healthcare, ultimately improving care and rehabilitation outcomes for forensic service users.
AshworthS.BrowneK. D.TullyR. J. (2018). A systematic review exploring the quality and effectiveness of tools currently utilized to measure attitudes toward prisoner populations: Exploring reliability and validity. Journal of Forensic Psychology Research and Practice, 18(1), 19–44. https://doi.org/10.1080/24732850.2017.1409605
2.
BergenN.LabonteR. (2019). Everything is perfect, and we have no problems: Detecting and limiting social desirability bias in qualitative research. Qualitative Health Research, 30(5), 783–792. https://doi.org/10.1177/1049732319889354
3.
BlowA. J.SprenkleD. H.DavisS. D. (2007). Is who delivers the treatment more important than the treatment itself? The role of the therapist in common factors. Journal of Marital and Family Therapy, 33(3), 298–317. https://doi.org/10.1111/j.1752-0606.2007.00029.x
4.
CharlesJ. L. K.BentleyK. J. (2018). Measuring mental health provider-based stigma: Development and initial psychometric testing of a self-assessment instrument. Community Mental Health Journal, 54(1), 33–48. https://doi.org/10.1007/s10597-017-0137-4
CorriganP. W.KerrA.KnudsenL. (2005). The stigma of mental illness: Explanatory models and methods for change. Applied and Preventive Psychology, 11(3), 179–190. https://doi.org/10.1016/j.appsy.2005.07.001
7.
CremoniniV.PagnucciN.GiacomettiF.RubbiI. (2018). Health care professionals attitudes towards mental illness: Observational study performed at a public health facility in northern Italy. Archives of Psychiatric Nursing, 32(1), 24–30. https://doi.org/10.1016/j.apnu.2017.09.007
8.
Del Olmo-RomeroF.Gonzalez-BlancoM.SarroS.GracioJ.Martin-CarrascoM.Martinez-CabezonA. C.PernaG.Pomarol-ClotetE.VarandasP.Ballesteros-RodriguezJ.Rebolleda-GilC.VanniG.Gonzalez-FraileE. (2019). Mental health professionals’ attitudes towards mental illness: Professional and cultural factors in the INTER NOS study. European Archives of Psychiatry and Clinical Neuroscience, 269(3), 325–339. https://doi.org/10.1007/s00406-018-0867-5
9.
FoxA. B.EarnshawV. A.TavernaE. C.VogtD. (2018). Conceptualizing and measuring mental illness stigma: The mental illness stigma framework and critical review of measures. Stigma and Health, 3(4), 348–376. https://doi.org/10.1037/sah0000104
10.
FungK. M. T.TsangH. W. H.CorriganP. W. (2008). Self-stigma of people with schizophrenia as predictor of their adherence to psychosocial treatment. Psychiatric Rehabilitation Journal, 32(2), 95–104. https://doi.org/10.2975/32.2.2008.95.104
11.
Giralt PalouR.PratG.Romeu-labayenM.Tort-nasarreG. (2022). Analysis of stigma in relation to behaviour and attitudes towards mental health as influenced by social desirability in nursing students. International Journal of Environtmental Research and Public Health, 19, Article 3213. https://doi.org/10.3390/ijerph19063213
12.
GoffmanE. (1963). Stigma: Notes on the management of spoiled identity. Touchstone.
13.
GörzigA.RyanL. N. (2022). The different faces of mental illness stigma: Systematic variation of stereotypes, prejudice and discrimination by type of illness. Scandinavian Journal of Psychology, 63(5), 545–554. https://doi.org/10.1111/sjop.12833
14.
HarrisP. A.TaylorR.MinorB. L.ElliottV.FernandezM.O'NealL.McLeodL.DelacquaG.DelacquaF.KirbyJ.DudaS. N.ConsortiumR. E. (2019). The REDCap consortium: Building an international community of software platform partners. Journal of Biomedical Informatics, Jul;95, Article 103208. https://doi.org/10.1016/j.jbi.2019.103208
HealeyL. V. (2022). The psychometric properties of the Forensic Stigma Scale (FSS). International Journal of Law and Psychiatry, 83, Article 101804. https://doi.org/10.1016/j.ijlp.2022.101804
17.
HendersonC.NoblettJ.ParkeH.ClementS.CaffreyA.Gale-GrantO.SchulzeB.DrussB.ThornicroftG. (2014). Mental health-related stigma in health care and mental health-care settings. The Lancet Psychiatry, 1(6), 467–482. https://doi.org/10.1016/S2215-0366(14)00023-6
18.
HillbrandM. (2005). Obstacles to research in forensic psychiatry. Journal of the American Academy of Psychiatry and the Law, 33, 295–298.
19.
HirschfieldP. J.PiqueroA. R. (2010). Normalization and legitimation: Modeling stigmatizing attitudes toward ex-offenders. Criminology, 48(1), 27–55. https://doi.org/10.1111/j.1745-9125.2010.00179.x
20.
JauchM.OcchipintiS.O'DonovanA. (2023). The stigmatization of mental illness by mental health professionals: Scoping review and bibliometric analysis. PloS One, 18(1), Article e0280739. https://doi.org/10.1371/journal.pone.0280739
21.
JormA. F. (2015). Using the Delphi expert consensus method in mental health research. Australian and New Zealand Journal of Psychiatry, 49(10), 887–897. https://doi.org/10.1177/0004867415600891
KassamA.GlozierN.LeeseM.HendersonC.ThornicroftG. (2010). Development and responsiveness of a scale to measure clinicians’ attitudes to people with mental illness (medical student version). Acta Psychiatrica Scandinavica, 122(2), 153–161. https://doi.org/10.1111/j.1600-0447.2010.01562.x
24.
KitzingerJ. (2006). Focus groups. In PopeC.MaysN. (Eds.), Qualitative research in health care (3rd ed., pp. 1–520). BMJ Books. https://doi.org/10.1002/9780470750841.ch3
25.
KjelsbergE.SkoglundT. H.RustadA. B. (2007). Attitudes towards prisoners, as reported by prison inmates, prison employees and college students. BMC Public Health, 7, Article 71. https://doi.org/10.1186/1471-2458-7-71
26.
KnaakS.MantlerE.SzetoA. (2017). Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. Healthcare Management Forum, 30(2), 111–116. https://doi.org/10.1177/0840470416679413
27.
LammieC.HarrisonT. E.MacmahonK.KniftonL. (2010). Practitioner attitudes towards patients in forensic mental health settings. Journal of Psychiatric and Mental Health Nursing, 17(8), 706–714. https://doi.org/10.1111/j.1365-2850.2010.01585.x
28.
LauberC.AnthonyM.Ajdacic-GrossV.RosslerW. (2004). What about psychiatrists’ attitude to mentally ill people?European Psychiatry, 19(7), 423–427. https://doi.org/10.1016/j.eurpsy.2004.06.019
LewisG.ApplebyL. (1988). Personality disorder: The patients psychiatrists dislike. British Journal of Psychiatry, 153(1), 44–49. https://doi.org/10.1192/bjp.153.1.44
LivingstonJ. D.BoydJ. E. (2010). Correlates and consequences of internalized stigma for people living with mental illness: A systematic review and meta-analysis. Social Science & Medicine, 71(12), 2150–2161. https://doi.org/10.1016/j.socscimed.2010.09.030
34.
LivingstonJ. D.RossiterK. R. (2011). Stigma as perceived and experienced by people with mental illnesses who receive compulsory community treatment. Stigma Research and Action, 2(1), 1–8. https://doi.org/10.5463/SRA.v1i1.1
35.
MacLinM. K.HerreraV. (2006). The criminal stereotype. North American Journal of Psychology, 8(2), 197–208.
36.
MaglianoL.De RosaC.FiorilloA.MalangoneC.GuarneriM.MarascoC.MajM. (2004). Beliefs of psychiatric nurses about schizophrenia: A comparison with patients’ relatives and psychiatrists. International Journal of Social Psychiatry, 50(4), 319–330. https://doi.org/10.1177/0020764004046073
MollerhojJ. (2021). Offender recovery. Forensic patient perspectives on long-term personal recovery processes. International Journal of Environmental Research and Public Health, 18(12), Article 6260. https://doi.org/10.3390/ijerph18126260
39.
MøllerhøjJ.StølanL. O.Brandt-ChristensenM. (2016). A thorn in the flesh? Forensic inpatients in general psychiatry. Perspectives in Psychiatric Care, 52(1), 32–39. https://doi.org/10.1111/ppc.12099
40.
NeeC.WittC. (2013). Public perceptions of risk in criminality: The effects of mental illness and social disadvantage. Psychiatry Research, 209(3), 675–683. https://doi.org/10.1016/j.psychres.2013.02.013
41.
NordtC.RösslerW.LauberC. (2006). Attitudes of mental health professionals toward people with schizophrenia and major depression. Schizophrenia Bulletin, 32(4), 709–714. https://doi.org/10.1093/schbul/sbj065
42.
RaoH.PillayP.AbrahamA.LutyJ. (2009). A study of stigmatized attitudes towards people with mental health problems among health professionals. Journal of Psychiatric and Mental Health Nursing, 16(3), 279–284. https://doi.org/10.1111/j.1365-2850.2008.01369.x
43.
RossC. A.GoldnerE. M. (2009). Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: A review of the literature. Journal of Psychiatric and Mental Health Nursing, 16, 558–567. https://doi.org/10.1111/j.1365-2850.2009.01399.x
44.
SchmittJ.LanganS.StammT.WilliamsH. C. (2011). Core outcome domains for controlled trials and clinical recordkeeping in eczema: International multiperspective Delphi consensus process. Journal of Investigative Dermatology, 131(3), 623–630. https://doi.org/10.1038/jid.2010.303
45.
SchwartzR. C.SmithS. D.ChopkoB. (2007). Psychotherapists’ countertransference reactions toward clients with antisocial personality disorder and schizophrenia: An empirical test of theory. American Journal of Psychotherapy, 61(4), 375–393. https://doi.org/10.1176/appi.psychotherapy.2007.61.4.375
46.
SkipworthJ.HumberstoneV. (2002). Community forensic psychiatry: Restoring some sanity to forensic psychiatric rehabilitation. Acta Psychiatrica Scandinavica. 106(Supplementum 412), 47–53. https://doi.org/10.1034/j.1600-0447.106.s412.11.x
StangorC. (2009). The study of stereotyping, prejudice, and discrimination within social psychology. In NelsonT. D. (Ed.), Handbook of prejudice, stereotyping and discrimination (pp. 1–22). Psychology Press.
49.
StuberJ. P.RochaA.ChristianA.LinkB. G. (2014). Conceptions of mental illness: Attitudes of mental health professionals and the general public. Psychiatric Services, 65(4), 490–497. https://doi.org/10.1176/appi.ps.201300136
50.
SwartlingÅG (2007). Focus group (Advanced tools for sustainability assessment, European Commission). IVM.
51.
ThornicroftG.RoseD.KassamA.SartoriusN. (2007). Stigma: Ignorance, prejudice or discrimination?British Journal of Psychiatry, 190(3), 192–193. https://doi.org/10.1192/bjp.bp.106.025791
52.
TremlinR. C.BeazleyP. (2022). A systematic review of offender mental health stigma: Commonality, psychometric measures and differential diagnosis. Psychology, Crime & Law, 30(2), 1–25. https://doi.org/10.1080/1068316x.2022.2072842.
53.
TsangH. W.FungK. M.CorriganP. W. (2009). Psychosocial and socio-demographic correlates of medication compliance among people with schizophrenia. Journal of Behavior Therapy and Experimental Psychiatry, 40(1), 3–14. https://doi.org/10.1016/j.jbtep.2008.02.003
54.
VorstenboschE.Masoliver-GallachR.Escuder-RomevaG. (2022). Measuring professional stigma towards patients with a forensic mental health status: Protocol for a Delphi consensus study on the design of a questionnaire. BMJ Open, 12(9), Article e061160. https://doi.org/10.1136/bmjopen-2022-061160
55.
WalkdenS. M.RogersonM.Kola-PalmerD. (2021). Public attitudes towards offenders with mental illness scale (PATOMI): Establishing a valid tool to measure public perceptions. Community Mental Health Journal, 57(2), 349–356. https://doi.org/10.1007/s10597-020-00653-0
56.
WangK.LinkB. G.CorriganP. W.DavidsonL.FlanaganE. (2018). Perceived provider stigma as a predictor of mental health service users’ internalized stigma and disempowerment. Psychiatry Research, 259, 526–531. https://doi.org/10.1016/j.psychres.2017.11.036
57.
WestM. L.MulayA. L.DeLucaJ. S.O’DonovanK.YanosP. T. (2018). Forensic psychiatric experiences, stigma, and self-concept: A mixed-methods study. The Journal of Forensic Psychiatry & Psychology, 29(4), 574–596. https://doi.org/10.1080/14789949.2018.1425473
58.
WestM. L.YanosP. T.MulayA. L. (2014). Triple stigma of forensic psychiatric patients: Mental illness, race, and criminal history. International Journal of Forensic Mental Health, 13(1), 75–90. https://doi.org/10.1080/14999013.2014.885471
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
