When Health Care Workers Experience Mental Ill Health

Workers’ Practices of Concealment

Whether the workers were frontline staff or high-level managers, they all described strategies they implemented to manage information about their past histories or current struggles with mental health issues. For some, concealing their issues seemed to be a form of “work” that they engaged in on a daily basis. One worker stated,

A part of what ended up happening, I became a perfectionist at work and I took on way more than my mind and my body probably could have handled just to cover up what was really happening with me. . . . I didn’t want anybody to see how bad, upon reflection, I was feeling or how bad—I didn’t want people to see how hard it was to cope, to manage. It was basically trying to get to work . . . the focus was to be able to survive at work. So everything else went—the house went, the kids went.

Many participants talked about their personal investment in work; work was important and meaningful, as was their image of competence as a worker. Workers explained that even during times when they were struggling, they worked hard to conceal any impact on their work performance. Some adopted strategies such as going in to work on weekends or staying late to make up for the days on which they were less productive. One participant talked about planning days off as vacation or lieu (i.e., compensatory or “comp”) time when she felt tension building, and doing so in a way that would not only hide her problems, but limit inconvenience to other members of the team. It was as if the workers tried to maintain their image of competence at all costs.

Practices of concealment were related not only to current struggles, but to the participants’ respective histories of mental health issues. Several workers explained that they were careful not to reveal information about a prior mental health issue because it might jeopardize their reputation. One participant in a management position explained that she did not want to “talk about anything that’s gonna be perceived as some kind of weakness.” Another participant, who was a frontline service provider, talked about her fear that someone might find out about her history of mental health issues: “What if somebody knew? . . . I would lose my authority.” As a result, she avoided therapy situations in which she might be recognized and was careful to ensure that there were privacy restrictions on her medical records. Concealment meant working hard to disguise current or past experience with mental illness, and to project an image of competence at work.

Strategic Disclosure by Workers

Although many participants worked hard to conceal their mental health issues, there were times when the silence was intentionally broken and they disclosed to others in the workplace. Disclosure was not an all-or-nothing process; workers were selective and strategic not only about what they said, but when they said it and to whom. Disclosure practices revealed implicit rules about silence and managing one’s reputation in the workplace. One example of strategic disclosure was described as “testing the waters” by making indirect references to personal experience with mental illness and then watching for the responses of others. One worker, for example, explained, “Every once in a while I do ‘lob’ [toss out a hint or clue about] things . . . but I’ve never really come straight out about my own experience.” Another related that she would “pick and choose” what she would share based on her perception of the specific situation. The social context for sharing information seemed to be important as a testing ground to see how others would respond.

Workers were also strategic about the content of what they shared with others. One participant, for example, explained that she was less likely to disclose an addiction issue than a family history of mental illness or a seasonal mood disorder. She felt that her addiction issues would present a greater risk to her reputation. Another worker reported that he shared information about his past history of addiction issues but did not disclose his current struggles. Selective disclosure, therefore, involved sharing “safer” information (e.g., past rather than current experience), and might only be partial disclosure in the form of innuendo or indirect comments.

There were several different contexts within which strategic disclosure took place. The first relates to disclosure in the context of supporting a client. Disclosure to a client was depicted as an exceptional circumstance and not part of typical practice. Several clinicians shared examples of disclosure that did not happen right away, but rather occurred as they were conveying empathy and support to an individual who was struggling. When revealing their personal histories, they perceived this to be supportive to the client; however, they were quick to point out that disclosure of this nature was considered to be a violation of a professional code regarding therapeutic boundaries. In fact, one service provider explained that she was fired from a previous position because she had shared personal information about her use of psychiatric medication.

Another form of strategic disclosure took place within the context of advocacy in the workplace on behalf of individuals with mental health issues and their needs. Participants identified this type of disclosure as important, although it was associated with considerable personal risk to the workers’ reputations. One worker, for example, spoke with passion about her “stigma-busting” efforts through public disclosure of her history of mental health issues. She, like others, felt initial reluctance or trepidation to expose her personal experiences. Advocacy through public disclosure was also characterized as hard work at times, and individuals did not always feel up to the challenge. One participant, for example, lamented, “Other times I just feel too burnt out and I just let it go. It’s like I don’t want to be fighting all the time.” She felt that sometimes maintaining silence was easier than engaging in advocacy efforts.

A third form of disclosure was linked to the need to maintain one’s image of competence and reputation in the workplace. When work performance started to decline to the point that others would notice, disclosing struggles with mental health issues became a strategy for some workers to explain their behavior and negotiate support. One participant, for example, explained that she felt as if she was letting her colleagues down when calling in sick, and was afraid there would be complaints about her use of sick time. She chose to disclose to her manager because “[i]t would be against their whole philosophy to criticize someone who is off with mental health issues. . . . That’s why I wanted her [manager] to know that it was mental health and not me buggering off [shirking my duty] on a long weekend.” She went on to explain “[t]hat this isn’t the real me. This isn’t the normal me. This is very stressed me and eventually I’ll do a better job.”

Information sharing was precipitated by questions that were being raised about the worker’s ability to perform. The implications of being identified as ill seemed to be weighed against the implications of being identified as a bad employee; disclosure became a strategy of last resort to salvage one’s social identity as a good worker. Regardless of the context, when workers chose to share their personal experiences, this was managed carefully and strategically because it was outside the accepted practices of silence within the organization. It was not easy and, for many, it meant risking their reputation in the workplace.

Collective Inaction Among Workplace Stakeholders

Thus far, we have discussed strategies that workers used to conceal their mental health issues from others. There were times, however, when concealment was not effective. When issues became visible, one response of others in the workplace was to do nothing; they ignored the issues and looked the other way. Stories existed in all areas of the organization, from housekeeping and administration to frontline clinicians and high-level managers—about staff members who struggled for a long time before their issues were acknowledged or addressed by anyone in the workplace. A common thread in these stories was that issues were evident for weeks or even months, yet often escalated to a point of crisis before they were openly acknowledged and addressed.

One of the union representatives talked about an office employee who struggled for months with mental health issues until he was found cowering under his desk one morning. She expressed concern that his coworkers ignored his struggles. We heard a similar story about a worker with a drug problem who was ignored until his explosive outburst in the workplace demanded attention. The irony of silence surrounding mental health issues in a mental health care facility was noted by many participants. Many stories revealed that issues often had to reach “a huge breaking point” before the silence was broken.

The Cloak of Secrecy Among Colleagues

In some cases, we heard that coworkers covered for their colleagues who were struggling. One manager dubbed this coworker silence as a “cloak of secrecy,” explaining, “People cover for one another, and they protect one another. They don’t want their friends in trouble.” According to this manager, there seemed to be a posture of protection, particularly if the employee was popular. Similarly, another manager reported, “If they are liked by the general group, they’ll cover for them. They’ll hide them, they’ll do their work, that kind of stuff.” If the employee was not well liked and appeared to be struggling, however, then this protection might not happen: “If people think that you are a whiner or a problem employee and you have even a death [in the family], someone will go, ‘Oh, you are always having a crisis!’” Another reason for coworker secrecy might be to avoid being seen as the company snitch, or as someone who wanted to “raise trouble.” Several participants hypothesized that coworkers might decide not to say anything to maintain their own reputation. One of the workers explained, “People don’t want to intrude on other people’s toes. They just want to mind their own business.” As a result, coworkers were reluctant to say something when they noticed that a colleague was ill.

Implicit and Explicit Messages to Be Silent

In many situations, there seemed to be implicit or explicit messages to maintain silence regarding the mental health issues of employees. Several participants, for example, explained that they initiated dialogue with their managers and had their concerns dismissed. In some cases, workers initiated concerns about their own mental health; in other cases colleagues expressed concerns about the mental health of a coworker. One worker, for example, confessed to her manager about the difficulty she was having in managing her work and her fears that she was “burning out.” The response of the manager was, “There is nothing we can do.” The worker felt that her concerns were dismissed. Similarly, another worker recounted, “Anything that I have brought up [to my manager] has been pretty quickly brushed aside.” Her attempt to open a dialogue was shut down.

Other implicit messages to stay silent included gossip and innuendo about the unacceptability of mental health issues at work. Several participants referred to gossip within the organization about staff members with known mental health issues and how the competence of those workers was often called into question. One worker complained, “There is a grapevine [chain of gossip] here that does people a lot of damage.” Another participant who publicly disclosed her history of mental illness explained that the most dramatic and unexpected response to her disclosure was that of silence:

What I wasn’t expecting was the overwhelming reaction, and that was silence. I mean, knife-cutting, no-eye-contact, scurry-out-of-the-nursing-station-as-quickly-as-possible silence. I didn’t understand why people were just visibly uncomfortable around me and had no idea what to say.

Although implicit, these were clearly very strong messages in terms of the unacceptability of mental health issues among employees.

Many participants also revealed explicit directives about the unacceptability of disclosure. One participant, for example, mentioned to a coworker one day that she was looking for help with her mental health issues and was surprised by the response she received. Instead of offering suggestions, the coworker stated, “Oh my God, don’t tell me. Don’t tell anyone.” Another worker was told that it would be “career suicide” to disclose her issues in a public forum. These messages were warnings not to disclose personal experiences of mental illness. The examples of implicit and explicit messages highlight how colleagues in the workplace were actively engaged in enforcing unwritten rules about the silence surrounding mental health issues.

Organizational Gaps in Communication

Practices of silence in some cases seemed to go beyond individual action and appeared to be embedded within institutional practices. Gaps in communication were particularly evident in relation to sick leave and return to work. Several participants reported that when a worker was on a mental-health-related sick leave, it was as if the worker had disappeared from the workplace. There was very little acknowledgement of the employee’s situation or dialogue regarding his or her whereabouts. One participant recalled a situation when a colleague was off on sick leave:

Staff have been told nothing. They still have his office. There’s somebody covering his position two years later. His shoes are still in the office. His sweater is hanging up. All his personal effects are there. And people that he worked with have been told nothing. There’s this real discomfort around—like we want to send him a card. We want to know if he’s okay, but we don’t get any information.

Organizational silence extended to the return-to-work process as well. One employee talked about feeling “banished” from the workplace and then feeling “undermined” on her return to work because none of her managerial colleagues were notified of her intended return. Similarly, another worker described her return to work following a mental-health-related sick leave as extremely challenging. She explained that for weeks she had planned her return to work with her employer, yet on the day of her return, there was nowhere for her to sit. She had to wait in the hallway until someone arranged to find a desk for her. The replacement worker who had been hired temporarily to cover her work had claimed her space. “When I came back on the Monday, she had her name over my name on the door and all my pictures were off the bulletin board. And there were ones on the board of her stuff.” She felt as if she had to work to reclaim her position in the workplace.

A related issue that emerged repeatedly regarding sick leave and return to work was the lack of communication between stakeholders. Occupational health providers, managers, and union representatives all complained that they were left out of the communication loop, and they felt as if they were the last to be notified. Occupational health staff, for example, argued that they were supposed to be contacted when a worker was ill; however, they felt that employees and managers often acted without their input. Similarly, managers reported that they were “not privy to anything,” that they received very little information from occupational health and human resource staff about employees who were off for or returning from a mental-health-related sick leave. Union representatives also felt as if they were left out of the communication process, explaining that they got “lots of these after-the-fact calls.” Each stakeholder seemed to blame others for the lack of communication.

Disjuncture Between Silence and the Public Mandate of Open Dialogue

It is ironic to note that the pervasive practices of silence were embedded within an organization that espoused the importance of an open dialogue and advocacy regarding mental illness. The corporate brochure and annual reports, for example, profiled how the organization improved lives of those with mental illness, not only through direct treatment, but also through public education in local, national, and international arenas. Raising awareness, reducing stigma, and creating a public dialogue regarding mental illness was a central component of the organization’s fundraising campaigns. Many participants referred to their personal commitment to these organizational principles. Several managers, for example, talked about the importance of having a higher standard in the organization when it came to supporting individuals with mental health issues: “We try and practice what we are preaching.”

This public discourse of leadership and open dialogue stood in stark contrast to the day-to-day embodied experience of workers in the organization whose mental health issues were often surrounded by secrecy and silence. Many participants talked about the irony inherent in working in a mental health care organization that did not acknowledge mental health issues in their own staff:

It’s weird that there’s this discomfort around speaking openly about it. There is such an irony. It’s a mental health institution and these are supposed to be mental health professionals, and yet they have such a hard time talking about mental health when it’s us and not the clients.

Talk about mental illness and addiction issues was seen as valuable and important, but only in reference to circumscribed others, such as clients or members of the public, not among staff within the organization.

In summary, the study findings characterize silence, not as the absence of talk, but as an active practice taken up by workers at all levels of the organization and embedded within the practices of the organization itself. Establishing, maintaining, enforcing, and reinforcing silence regarding the mental health issues of workers appeared to be a dynamic process embedded within a complex web of social relations.

Micro-Level Perspective: Silence and Stigma

One potential explanation for ubiquity of silence relates to the function that it served in preventing stigma and discrimination of workers with mental health issues. Practices of concealment adopted by workers in our study are similar in many ways to the impression-management strategies that Goffman (1959) described in his seminal work on stigma. Impression management, according to Goffman, involves carefully managing information about a hidden disability to guard against being discredited. Even the workers’ strategies of selective and strategic disclosure parallel Goffman’s descriptions of the “innuendo, strategic ambiguity and crucial omission” strategies used to salvage one’s social identity (1959, p. 62).

The actions of workers were also similar to that which Church, in her study of disabled employees, referred to as the “choreography of concealing.” She characterized the process of concealing one’s disability as choreography in that it can be “highly elaborate, characterized by invisible micro-decisions within each transactional moment in the workplace” (2006, p. 12). From this vantage point, the worker is an active agent in practices of concealment and projecting an identity of competence in the workplace.

A similar interactionist perspective can be used to understand stakeholders’ practices of silence. Many explanations of stigma and discrimination in the workplace are based on a view of stigma as defined and enacted through social interaction (Pescosolido, Martin, Lang, & Olafsdottir, 2008). Differences in the stakeholders’ practices of silence noted in this study (from covering for ill workers to ignoring requests for support) can be explained by variation in the perceptions of the ill worker. Social characteristics (e.g., age, role in the organization), illness characteristics (e.g., concealability, culpability), and behaviors (e.g., visibility, severity) have all been attributed to the process of marking and labeling the worker and, ultimately, how others respond (Pescosolido et al., 2008; St-Arnaud et al., 2006).

Not unlike the findings reported by others (Hinshaw, Cicchetti, Toth, 2006; St-Arnaud et al., 2006), coworkers in our study seemed to be supportive if the ill worker was well liked and his or her symptoms at work were considered to be a temporary reaction to a stressful experience. Coworkers covered for their ill colleagues at times and supported individual practices of concealment. Conversely, there were times when practices of silence were more punitive or dismissive. This alternative response might have been reflective of negative perceptions of the illness characteristics or behavior of the worker. Workers with mental health issues are often perceived to be incompetent and unreliable and, therefore, are likely to experience discrimination in the workplace (Krupa et al., 2009; Stuart, 2004). Workers’ attempts to project an image of competence through practices of silence make sense in light of day-to-day interactions within the workplace and their attempts to avoid discrimination.

Meso-/Macro-Level Perspective: Silence and Institutional Order

Accounting for practices of silence from a micro-level focus on workplace relationships tells only part of the story. We believe that day-to-day interactions in the workplace are embedded within a broader social context in which the actions of workers are shaped by meso- and macro-level forces, such as institutional and societal discourses regarding characteristics of the worker, as well as health, illness, and productivity. Day-to-day practices of silence, from an institutional ethnography perspective, are embedded within an institutional context that is outside the consciousness of individual workers (Smith, 2005).

Rather than simply making decisions about how they present to others, we hypothesize that workers’ actions are unconsciously embedded in and shaped by an institutional discourse on what it means to be a “good worker.” Within this discourse, workers are framed as healthy and competent; being ill is not socially acceptable. It might be that workers take up the discourse of competence and, in their efforts to be good workers, they ignore or conceal the signs of illness. Workplace stakeholders, like the workers, might take up the same discourse. In this process, they become involved in enforcing rules about productivity and performance, including direct and indirect messages about the unacceptability of mental health issues among employees. Employees who do not meet the standards of the “good worker” in a “perfect workplace” are marginalized or silenced.

Silence and the Social Relations of Health Care

The functions of silence reported in this study might operate in many workplaces and are not necessarily specific to health care. The context of the mental health care environment, however, might create particular conditions for the production of silence. In fact, the smooth functioning of the organization seemed to be dependent on a distinction between healthy service providers and ill service recipients.

The mental health care organization in our study was socially organized in particular patterns of social relations, interactions, and authority that contributed to the business of the workplace: providing services to address the needs of patients or clients who had mental illness. Distinctions between staff and clients were reinforced in a material way by clearly demarked spaces for clients vs. staff and by outward markers of staff identities (e.g., name tags, keys). To provide quality health care and meet implicit standards of “good health care workers,” it might have been imperative for staff to appear healthy and competent.

This discourse of professional competence is consistent with other research regarding the professional ideology of health care service providers and their reluctance to admit illness (Crout et al., 2005; Rosvold & Bjertness, 2001). If institutional order is dependent on healthy service providers, open acknowledgment of mental health issues could disrupt the order of business and blur the boundaries between service provider and service recipient. Consequently, concealing information about a current or past history of mental health issues, ignoring signs of ill health among workers, and lack of communication between stakeholders are ways to maintain the idealized image of workers and the institutional order.

Paradoxical Consequences of Silence

Although silence seems to serve a function in maintaining institutional order and the idealized image and reputation of workers, the practices of silence might in fact be a double-edged sword. The benefits of silence for workers, workplace stakeholders, and the organization are counterbalanced by risks to the health of workers, workplace relationships, and ultimately the reputation and quality of care provided by the organization. In some cases, silence maintains the idealized image and reputation of the workers because their struggles with mental health issues are not made public. There are risks, however, to the silence if the workers’ investment in projecting an image of competence prevents them from seeking help. Furthermore, if others ignore the issues or look the other way, there is little support for the worker who might be struggling and in need of support. Delays in seeking treatment can ultimately increase the duration of sickness absence (Brouwers, Terluin, Tiemens, & Verhaak, 2009). If mental health problems remain untreated, they might escalate over time and the reputation of the worker could ultimately be at risk, particularly if the problems proceed to the point of crisis.

Another paradoxical consequence of silence relates to its impact on workplace relationships. In the short term, secrecy regarding workers with mental health issues might be a way of protecting confidentiality and avoiding uncomfortable discussions. Ultimately, however, social tensions might escalate over time if issues are not addressed. Ignoring “the elephant in the room” does nothing to resolve the situation, and it might, in fact, perpetuate the stigma associated with mental illness (Stuart, 2006).

A third paradox associated with silence concerns the functioning of the organization as a whole. As argued earlier, practices of silence might serve to maintain institutional order because distinctions between service providers and service recipients are not challenged, and the idealized image of the service provider is perpetuated. Ultimately, however, if the workplace environment does not support mental well-being and if workers do not get the help they need to maintain their performance at work, quality of care might deteriorate and the reputation of the organization might suffer (Rosvold & Bjertness, 2001).

Implications of the Study Findings

There are several implications of the paradoxical consequences of silence for theory and practice in workplace mental health. In particular, the study findings serve to inform our understanding of disclosure and of workplace supports for individuals with a mental illness. Disclosure is an issue that is frequently discussed in relation to mental illness in the workplace (MacDonald-Wilson, 2005). Much of the literature characterizes disclosure as an “all-or-nothing” event, and the outcome of a conscious decision about whether or not to share information (Goldberg, Killeen, & O’Day, 2005; Schulze & Angermeyer, 2003).

The findings of our study point toward a more nuanced picture of disclosure as a social process. Rather than viewing disclosure as something that a worker did or did not do, we have highlighted variations in practices of sharing information over time, and the strategic and selective approaches to sharing information within the social context of work. Other stakeholders in the workplace were involved, and the ways in which they received, perceived, and responded to shared information shaped the experiences and actions of workers. Impression management appears to have been an interactive, socially produced process embedded within broader institutional and societal discourses regarding what it meant to be a good worker. Furthermore, silence was not simply the antithesis of disclosure, but rather an active practice that served many functions for the individuals and organization.

This reconceptualization of disclosure as part of a complex social process has important implications for service providers who might be counseling workers about disclosure. Instead of simply discussing whether or not to disclose at the outset of employment, service providers might need to facilitate reflection on disclosure as a process that unfolds over time. Managing impressions in the workplace is a form of work, and how the work evolves might depend on an individual’s personal experience of symptoms, expectations of people around him or her, and the workplace culture. Instead of prescriptive advice regarding when, what, and how to disclose, service providers might need to broaden the discussion to include consideration of the practices of silence.

Workers might find it helpful to consider how impression management strategies not only protect from discrimination, but also how they absolve others from the need to provide support. Workers might not be aware of how they internalize expectations regarding silence, nor how others might silence their attempts to disclose. The study findings can serve to raise the consciousness of workers regarding silence and disclosure as embedded within organizational discourses. With increased awareness of these issues, workers can make informed choices regarding when and how to share their personal mental health information with others.

The study findings also inform how to support workers with mental health issues. Many best practice guidelines for workplace mental health emphasize the importance of an open dialogue between workplace stakeholders (Furlan et al., 2011; National Institute for Clinical Excellence, 2009; Pomaki et al., 2010). Proactive and clear communication is considered to be critical to early identification and support (Couser, 2008), initiation of workplace accommodations (Corbiere & Shen, 2006; Tetrick & Toney, 2002), and facilitating return to work (Caveen, Dewa, & Goering, 2006). Our study illuminates some of the barriers to open communication and the complex forces that produce and reproduce silence in the workplace. Although there might be benefits associated with moving beyond practices of silence, we have argued that there are also risks associated with change. There might be risks for workers in terms of stigma and discrimination, risks for colleagues related to social tensions, and risks for the organization in terms of disruption to institutional order. The interactive and structurally embedded nature of the silence practices casts doubt on suggested action points for change. Thoughtful reflection on both the positive and negative implications of sharing information in the workplace is needed.

In conclusion, silence surrounding mental health issues is not a new discovery, but this study is unique in the way we have analyzed silence and how it is produced and reproduced within the context of mental health care work. We have presented an anatomy of silence, exploring the different forms it might take, the ways in which it is enacted by stakeholders in the workplace, and how it is embedded within organizational practices. Silence has been characterized not as the absence of dialogue, but rather as an active practice that serves a range of functions for individuals and organizations. By describing day-to-day interactions and how they are embedded in and governed by broader social forces, we have cast light on the social relations of silence at the micro-, meso-, and macro levels, and the functions that silence serves in maintaining institutional order within a health care setting. We have argued that the silence surrounding the mental health of health care workers is complex, multidimensional, and, at times, even paradoxical. Moving beyond silence is not simply a matter of speaking out; it requires careful consideration of the risks and benefits for individuals and organizations.