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The evolving understanding of stigma

JUL 2010

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Theories differ about why it is so pervasive and so hard to eradicate.

It is difficult to get through a week (and sometimes a day) without hearing some disparaging remark or dismissive joke made about mental illness or the clinicians who treat psychiatric disorders. Stigmatizing views permeate popular culture.

Every October, for example, the National Alliance on Mental Illness identifies the latest "Halloween horrors" sold commercially, which have included costumes that look like straitjackets or enable people to dress up as "Dr. Malice" or "Cell Block Psycho." Aside from being distasteful, the constant background noise of stereotyped or inaccurate information contributes to the persistent stigma about mental illness.

From a clinical perspective, stigma is important because it contributes to delays in seeking treatment for mental health disorders and problems in accessing care. One nationally representative survey, for example, found that only 51% of Americans with symptoms of major depression in the previous year were receiving any kind of treatment, whether with antidepressants or psychotherapy. Another found that only about half of people with social anxiety disorder ever receive treatment. Typically they have symptoms for at least 10 years before seeking help. In both these studies, stigma was cited as an important factor.

Origins and interpretations

The word stigma is derived from the Latin term for a brand that marked someone as a slave or criminal. In much the same way, stigma about mental illness also "marks" people, although the understanding of how that process occurs — and how to address it — has evolved over time.

Dr. Erving Goffman, a sociologist who spent much of his career at the University of Pennsylvania, is credited with first articulating the modern concept of stigma as a personal attribute that results from the social construction of identity. In his 1963 book, Stigma: Notes on the Management of Spoiled Identity, he proposed that someone associated with a stigmatized condition progresses from "normal" to "deeply discredited" in society.

In subsequent years, psychologists continued to explore how a stigmatized individual internalizes this devalued social identity. These primarily psychological models suggest that stigma is harmful because it impairs self-esteem and other aspects of psychological well-being. This, in turn, threatens academic and professional achievement and mental health.

A more recent wave of sociological research has explored the importance of the social and cultural environment — both in perpetuating stigma and in eradicating it. For example, Dr. Patrick Corrigan, a psychologist at the Illinois Institute of Technology, has proposed that economic, political, and historical forces underlie stigma. According to this view, stigma functions like racism in that it promotes institutionalized forms of discrimination, such as restriction of voting rights.

Toward a moral model

Most recently, in a series of papers, Dr. Arthur Kleinman, a psychiatrist and medical anthropologist at Harvard University, has made the case that stigma has become such an overused term that it has lost any real meaning. Instead, he proposes a new term: social death. In an effort to unite both the psychological and sociological models, Dr. Kleinman and colleagues propose that stigma is a moral experience — a term that encompasses a set of social norms and obligations that constitute what is most important to people living in a particular community.

Much of this work is based on observations made about the way psychiatric disorders are viewed and treated in some of the world's emerging economic powers, such as China and India. According to the moral view, people who are stigmatized experience social death when others in society hold attitudes and behave in ways to turn the stigmatized person into an "other," or a non-person. This leads to dehumanizing treatment, such as making psychiatric patients in China wear outfits like those of prisoners, prohibiting them from participating in family gatherings, or — in the worst cases — chaining them and perpetrating other human rights violations. (According to moral theorists, the large number of Americans with psychiatric disorders who are living on the streets or incarcerated represents another example of a dehumanizing situation.)

The research on stigma is concerned about more than theory. If stigma is primarily psychological, then eradicating it may involve psychotherapy to help patients boost self-esteem. If it is more of a social construct, the way to fight it is through awareness campaigns to change public opinion and policies. And if stigma is a moral issue, then it may be necessary to advocate for basic human rights. Given that stigma about mental illness is so persistent, it is likely that all of these efforts may be necessary before psychiatric disorders are seen as illnesses rather than as jokes or personal failings.

Kleinman A, et al. "Stigma: A Social, Cultural and Moral Process," Journal of Epidemiology and Community Health (June 2009): Vol. 63, No. 6, pp. 418–19.

Yang LH, et al. "Culture and Stigma: Adding Moral Experience To Stigma Theory," Social Science and Medicine (April 2007): Vol. 64, No. 7, pp. 1524–35.

For more references, please see www.health.harvard.edu/mentalextra.