A total of 207 trainee psychiatrists were approached to participate in this survey. They were all members of the Flemish Association of Trainees in Psychiatry [Vlaamse Vereniging van Assistenten Psychiatrie (VVAP)], an association that keeps records of all trainee psychiatrists in Flanders. Psychiatry training in Flanders requires 5 years of intensive internship under the supervision of an approved senior resident. At least 2 years of the training are fulfilled in a university center, most of which are urban. Peripheral internships are usually rural. Internships provide complementary experience with biological psychiatry, neurology or internal medicine, and psychotherapy. It is worth noting that junior trainees in Flanders are in their first two years of training, with an age span between 25 to 27 years. At the end of their training, their mean age is 30 years, although the ages of the trainee psychiatrists were not included in the socio-demographical part of the study.

Associative stigma was conceptualized as the combined effects of three stigma-related experiences: (1) the frequency and intensity of devaluing and humiliating interactions with significant others generally and within the medical circle in particular[7]; (2) the degree to which psychiatric stigma was a focus of attention during medical and psychiatric training[6]; and (3) the level of identification with negative stereotypes in the media[21].

Because no questionnaires were available for measuring associative stigma among psychiatrists[10] at the time of this survey, we designed one for the specific purpose of this study. Our newly developed questionnaire contained an adaptation of existing instruments, as well as de novo constructed items. The particular stigmatization questionnaire that we used in this survey was composed of 21 questions about stigma from three perspectives. Ten questions were about subjective experiences of humiliation and devaluation and the resulting coping mechanisms[7,15]. This first 10-item section of the questionnaire is an amended version of the Family Interview Schedule (FIS) of the World Health Organization (1992). This interview was developed as a structured instrument for associative stigma among family members of psychiatric patients in order to evaluate the perception of psychiatric problems by others in the patients’ environment and the consequences for both the patient and his or her family (Sartorius and Janca, 1996)[28]. The following six items on the list were paraphrased from the FIS questionnaire for relatives to suit the situational context of trainees: “tendency to conceal”, “secretiveness”, “fear of being avoided or ignored”, “explanation”, “fear over hesitation to marry into the family” and “contact with others”. The following six questions of the questionnaire were about stigma during medical and psychiatric training and were based on topics found in the international literature on stigmatizing experiences of psychiatrists[6,10]. The final five questions were about stereotypical images of psychiatry and psychiatrists in the media[21]. This third part of the questionnaire was based on Pies’s article “Psychiatry in the Media: The Vampire, The Fisher King and the Zaddik” (2001). This article describes how psychiatrists are portrayed in popular films via a number of fixed stereotypes: the evil genius, the crazy doctor, and the miraculous healer. Four of these stereotypes based on characters from well-known films were described in the questionnaire (four items). The last question on the list asked whether trainees were ever subjected to comments about the film One Flew over the Cuckoo’s Nest when they suggested ECT. Currently, the negative image of this treatment and of psychiatry as a whole is strongly emphasized.

The questionnaire was not particularly demanding and took 10 min to complete. The answers were scored on a Likert scale ranging from “never” (0 points) to “once” (1 point) to “more than once” (2 points) to “often” (3 points). The overall level of stigmatization (total associative stigma) was defined as the sum of the points scored by all the answers given by a single respondent, with a minimum of 0 points and a maximum of 63 points.

A cover letter describing the aim of the study and informed consent, as well as the questionnaire, were sent to all members listed in the Flemish Association of Trainee Psychiatrists (VVAP), an association that keeps record all trainees psychiatrist in Flanders. The ethical committee of the University Center Sint-Jozef Kortenberg gave permission to conduct the survey. The recruitment of trainees took place in a uniform way. The cover letter described the aim of the research and stressed the importance of the anonymous collection of data. In a second mailing, which was sent out two months later, the trainees who had not yet replied to the original survey were again asked to fill in the questionnaire and send it back.

The results were analyzed using the Statistical Package for Social Sciences, Version 18.0 (SPSS Inc., Chicago, IL). A student t-test was used to compare the average total associative stigmatization scores of the different subgroups of trainee psychiatrists. The subgroups were composed of independent socio-demographic and educational variables.

In total, 151 of 201 participants (six letters were returned as undeliverable) completed and returned the questionnaire, resulting in a response rate of 75.1%. The descriptive data of the population of trainee psychiatrists are reported in Table 1. There was a major gender gap in the participating trainees: 49 were male, and 102 were female (67.5%). This corresponds to the male/female ratio of all trainee psychiatrists in Flanders. More than 4 in 5 of the respondents (85.4%) were in a steady relationship at the time, whereas 14.6% were single. Also, 54.3% of trainees taking part in the investigation were senior assistants. Thus, they had more experience in clinical practice. The remaining 45.7% were either first-year or second-year trainees. Of all trainees questioned, 62.9% practiced adult psychiatry, 35.8% practiced child and youth psychiatry, and 1.3% practiced both. A slight majority of trainee psychiatrists (59.6%) had a predominantly psychotherapeutic orientation, 24.5% had a biological orientation, and 12.6% had both. A large number of all trainees had somatic, neurological or liaison experience (66.9%) in addition to their psychiatric experience, whereas only 33.1% had worked exclusively in psychiatric settings.

The Cronbach’s α of the questionnaire used in this investigation was 0.71, showing sufficient internal consistency.

The mean total stigma score (sum of all scores on the individual items) among our large cohort of trainee psychiatrists was 15.8 (SD ± 7.2). The most striking results were the following: 114 trainee psychiatrists (75.5%) claimed to have had denigrating or humiliating remarks about the psychiatric profession directed at them more than once. Also, 98 of them (65%) had had remarks about the incompetence of psychiatrists directed at them, typically related to psychiatrists not being real doctors, and 105 trainees psychiatrists (66.3%) had not been taken seriously by colleagues because of the nature of their profession. Among respondents, 74 (49%) had received discouraging remarks from tutors in university about their career choice. Only seven (1.3%) of these young doctors remembered stigma as a topic during their psychiatric training. In addition, 112 (74.2%) of the trainees had felt stigmatized as psychiatrists within the professional medical environment, although only 43 (28.5%) of them had ever considered a career switch. Questions about cinematic psychiatrist stereotypes showed no significant results. Only the stereotype of the crazy psychiatrist was mentioned by 57 trainees (37.7%). The full results of the stigmatization questionnaire are presented in Table 2.

There were no significant differences in mean total stigma scores between male and female trainees (15.49 ± SD 7.9 vs 15.94 ± SD 6.8, t = -0.343 and P > 0.05) or between those who were single and those in steady relationships (17.36 ± SD 8.1 vs 15.53 ± SD 7.0, t = -0.998 and P > 0.05). No differences were found between trainees with a biological orientation and those with a psychotherapeutic background (mean total stigma scores of 16.54 ± SD 6.7 vs 15.41 ± SD 7.0, t = 0.85 and P > 0.05). There was a borderline significant difference between those working with adults and those working with children and adolescents (mean total stigma scores of 16.53 ± SD 7.7 vs 14.33 ± SD 6.0, t = 1.924, P = 0.057). Trainees who had been in training for a longer period of time had experienced a significantly higher level of stigmatization than trainees with fewer years of experience (mean total stigma scores of 16.93 ± SD 7.8 vs 14.45 ± SD 6.1, t = -2.179 and P < 0.05, Figure 1).

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Figure 1 Mean total stigma scores related to sociodemographic and educational variables of trainee psychiatrists.

The most interesting results revealed on the analysis of the individual coping items on the questionnaire were the following: senior trainees kept quiet about their profession significantly more often than their junior colleagues (mean item score 0.44 ± SD 0.82 vs 0.13 ± SD 0.48, t = 2.874, P < 0.01). Comparable results were found among trainees working in adult psychiatry vs those working in child or youth psychiatry (mean item score 0.38 ± SD 0.77 vs 0.15 ± SD 0.53, t = -2.153, P < 0.05). Biologically oriented trainees were more inclined to give preventive explanations regarding their profession (mean item score 2.05 ± SD 1.05 vs 1.34 ± SD 1.1, t = -3.403, P < 0.01) than those who were more psychotherapeutically oriented. The level of feelings of incompetence in comparison to colleagues working in somatic medicine was marginally higher bur not statistically significant among female trainee psychiatrists than among male trainees (mean item score 1.24 ± SD 1.15 vs 1.62 ± SD 1.08), and the same applied to more senior trainees vs junior trainees (mean item score 1.66 ± SD 1.05 vs 1.3 ± SD 1.17). Significantly more male trainees than female trainees reported being refused by patients during a consultation simply because of their psychiatric profession (mean item score 1.24 ± SD 1.01 vs 0.85 ± SD 0.99, t = 2.246, P < 0.05), whereas the number of biologically oriented trainee psychiatrists who were refused was only marginally higher but not statistically significant than the number of trainee psychotherapists (mean item score 1.32 ± SD 1.1 vs 0.94 ± SD 0.95). Female trainee psychiatrists felt significantly more stigmatized within the professional category of medical doctors than their male counterparts (mean item score 1.2 ± SD 1.02 vs 0.84 ± SD 1.03, t = -2.020, P < 0.05), and the same was true for those who had more years of training compared to junior trainees (mean item score 1.28 ± SD 1.03 vs 0.87 ± SD 0.1, t = 2.337, P < 0.05).

Stigma is defined as a discrediting or disgracing mark, usually leading to negative behavior on the part of its bearer. Different approaches have been used to conceptualize psychiatric stigma, and are still evolving. Aspects such as devaluation, discrimination, decreased self-esteem, self-restricted behavior, and dysfunctional coping are almost always mentioned. Associative stigma is an extension of psychiatric stigma to those who care for patients, such as family members and mental healthcare workers, including psychiatrists. Multiple factors may contribute to the substantial associative stigma among psychiatrists: wrong basic assumptions on psychiatric treatments and limited awareness on the intensity and duration of psychiatry training.

Scientific data on associative stigma among psychiatrists are very scarce, although theoretical considerations are abundant. Scientific evidence on the extent of associative stigma among trainee psychiatrists is lacking in the current literature. There are reasons to believe that medical students are negatively influenced by associative stigma to make the choice for psychiatry as a career. Given the mental health gap, a continuing diminishing number of trainees worldwide would have devastating effects on mental health care in the future.

Trainee psychiatrists in Flanders mention feelings of stigmatization within society in general and the medical environment in particular. Associative stigmatization is thus a marked problem for young psychiatrists in training. They are labeled only because of their choice of profession, resulting in negative connotations that ultimately lead to devaluation. Besides, they develop coming mechanisms to deal with it. This might have a devastating impact not only on their wellbeing, but finally on decreasing number of candidates in psychiatry training.

The problem of stigmatization and its influence on the subjective feeling of well-being seems to be underestimated in university and training hospitals. More efforts have to be made to correct this. It could also be useful to begin anti-stigma campaigns during medical training in order to avoid a decrease in the number of candidate psychiatrists. The authors also suggest that trainers and supervisors carefully listen to and deal with the doubts, devaluing experiences, and signs of burnout of their trainees.

Associative stigma is an extension of psychiatric stigma to those who care for patients, such as family members and mental healthcare workers, including psychiatrists. The mental health care gap is the diminishment of the number of candidates for mental healthcare in the population of medical students. Coping mechanisms are conscious psychological adaptations to environmental stress, in order to obtain more comfort.

This study addresses a critical issue in professional training and clinical practice in the psychiatric field. The article has an important place as starting point for research into the area of stigmatization of trainee psychiatrists, as it made clear that the phenomenon is underestimated and impacts the mental health care gap.