Stigma

Definitions

The 1999 report on mental health by the Surgeon General of the United States was regarded as a landmark document in the United Kingdom, as well as the United States. This was because of its straightforward identification of the stigma associated with mental illness as the chief obstacle to effective treatment of persons with mental disorders. Stigma (plural, stigmata) is a Greek word that in its origins referred to a kind of tattoo mark that was cut or burned into the skin of criminals, slaves, or traitors in order to visibly identify them as blemished or morally polluted persons. These individuals were to be avoided or shunned, particularly in public places. The word was later applied to other personal attributes that are considered shameful or discrediting.

Social psychologists have distinguished three large classes, or categories, of stigma:

• Physical deformities. These include extremes of height and weight and such conditions as albinism and facial disfigurements or missing limbs. In the developed countries, this category also includes such signs of aging as gray hair, wrinkles, and stooped posture.
• Weaknesses or defects of individual character. This category includes biographical data that are held to indicate personal moral defect, such as a criminal record, addiction , divorce, treatment for mental illness, unemployment, suicide attempts, etc.
• Tribal stigma. This type of stigma refers to a person's membership in a race, ethnic group, religion, or (for women) gender that is thought to disqualify all members of the group.

The nature of stigma

Origins

One explanation for the origin of stigmata is that its roots in the human being's concern for group survival at earlier times in their evolutionary journey. According to this theory, stigmatizing people who were perceived as unable to contribute to the group's survival, or who were seen as threats to its well-being, were stigmatized in order to justify being forced out or being isolated.

The group survival theory is also thought to explain why certain human attributes seem to be universally regarded as stigmata, while others are specific to certain cultures or periods of history. Mental illness appears to be a characteristic that has nearly always led to the stigmatization and exclusion of its victims. The primary influences on Western culture, the classical philosophical tradition of Greece and Rome, and the religious traditions of Judaism and Christianity indicate that mental illness was a feared affliction that carried a heavy stigma. The classical philosopher's definition of a human being as a "rational animal" excluded him or her who had lost the use of reason and was no longer regarded as fully human; most likely he or she was under a divine curse. This attitude was summarized in the well-known saying of Lucretius, "Whom the gods wish to destroy, they first make mad."

In the Bible, both the Old and the New Testaments reflect the same fear of mental illness. In 1 Samuel 21, there is an account of David's pretending to be insane in order to get away from the king of a neighboring territory. "He changed his behavior before [the king's servants]; he pretended to be mad in their presence. He scratched marks on the doors of the gate, and let his spittle run down his beard." The king, who was taken in by an act that certainly fits the Diagnostic and Statistical Manual of Mental Disorders criteria for malingering , quickly sent David on his way. In the New Testament, one of Jesus' most famous miracles of healing (Mark 5:1-20) is the restoration of sanity to a man so stigmatized by his village that he was hunkered down in the graveyard (itself a stigmatized place) outside the village when Jesus met him. Mark's account also notes that the villagers had tried at different times to chain or handcuff the man because they were so afraid of him. One important positive contribution of Biblical heritage, however, is a sense of religious obligation toward the mentally ill. Among Christians, the New Testament's account of Jesus' openness to all kinds of stigmatized people—tax collectors, prostitutes, and physically deformed people, as well as the mentally ill—became the basis for the establishment of the first shelters and hospitals for the mentally ill.

Contemporary contexts

The core feature of stigma in the modern world is defined by social psychologists as the possession of an attribute "that conveys a devalued social identity within a particular context." Context is important in assessing the nature and severity of stress that a person suffers with regard to stigma. Certain attributes, such as race or sex, affect an individual's interactions with other people in so many different situations that they have been termed "master status" attributes. These have become the classic identifying characteristic of the person who possesses them. Dorothy Sayers' essay, "Are Women Human?" is not only a witty satire on the way men used to describe a woman's job or occupation (with constant reference to feminine qualities), but a keen social analysis of the problems created by master status attributes for persons who are stigmatized.

Other forms of devalued social identity are relative to specific cultures or subcultures. In one social context, a person who is stigmatized for an attribute devalued by a particular group may find acceptance in another group that values the particular attribute. A common example is that of an artistically or athletically talented child who grows up in a family that values only intellectual accomplishment. When the youngster is old enough to leave the family of origin, he or she can find a school or program for other students who share the same interest. A less marked contrast, but one that is relevant to the treatment of mental illness, is the cultural differences with regard to the degree of response to certain symptoms of mental illness. A study conducted in the early 21st century assessed the reaction of family members to elderly people who were diagnosed with Alzheimer's disease (AD). Findings pointed to considerable variation across racial and ethnic groups. Asian Americans were most affected by feelings of shame and social stigma relative to the memory loss of a family member, while African Americans were the least affected.

One additional complicating feature of stigma is the issue of overlapping stigmata. Many people belong to several stigmatized groups or categories, and it is not always easy to determine which category triggers the unkind or discriminatory treatment encountered. For example, one study of the inadequate medical treatment that is offered to most HIV-positive Native Americans noted that the stigma of Acquired Immune Deficiency Syndrome (AIDS) provides a strong motivation for not seeking treatment. The study protocol, however, did not seek to investigate whether young Native American men are afraid of being stigmatized for their sexual orientation, their race, their low socioeconomic status, or all three.

Stigma and mental illness

Stigma and specific disorders

The stigma that is still attached to mental illness in the developed countries does not represent a simple or straightforward problem. Public health experts who have studied the stigmatization of mental illness in recent years have noted that the general public's perception of mental illness varies, depending on the nature of the disorder. While in general the stigma of mental illness in contemporary society is primarily associated with the second of the three categories of stigma listed above,— supposed character failings—it also spills over into the first category. Mental disorders that affect a person's physical appearance—particularly weight gain—are more heavily stigmatized than those that do not.

The stigma related to certain types of mental disorders has declined since the 1950s, most notably in regard to depression and the anxiety disorders. It is thought that the reason for this change is that people are more likely nowadays to attribute these disorders to stress, with which most people can identify. On the other hand, the stigma associated with psychotic disorders appears to be worse than it was in the 1950s. Changes in public attitude are also reflected in age-group patterns in seeking or dropping out of treatment for mental disorders. One study demonstrated that older adults being treated for depression were more likely than younger adults to drop out of treatment because they felt stigmatized. The difference in behavior is related to public attitudes toward mental illness that were widespread when the older adults were adolescents.

In 2002, the types of mental disorders that carry the heaviest stigma fall into the following categories:

• Disorders associated in the popular mind with violence and/or illegal activity. These include schizophrenia , mental problems associated with HIV infection, and substance abuse disorders.
• Disorders in which the patient's behavior in public may embarrass family members. These include dementia in the elderly, borderline personality disorder in adults, and the autistic spectrum disorders in children.
• Disorders treated with medications that cause weight gain or other visible side effects.

The role of the media

The role of the media in perpetuating the stigmatization of mental illness has received increasing attention from public health researchers, particularly in Great Britain. In 1998, the Royal College of Psychiatrists launched a five-year campaign intended to educate the general public about the nature and treatment of mental illness. Surveys conducted among present and former mental patients found that they considered media coverage of their disorders to be strongly biased toward the sensational and the negative. One-third of patients said that they felt more depressed or anxious as a result of news stories about the mentally ill, and 22% felt more withdrawn. The main complaint from mental health professionals, as well as patients, is that the media presented mentally ill people as "dangerous time bombs waiting to explode" when in fact 95% of murders in the United Kingdom are committed by people with no mental illness. The proportion of homicides committed by the mentally ill has decreased by 3% per year since 1957, but this statistic goes unreported. Much the same story of unfair stigmatization in the media could be told in the United States, as the Surgeon General's report indicates.

Physicians' attitudes toward mental illness

Physicians' attitudes toward the mentally ill are also increasingly recognized as part of the problem of stigmatization. The patronizing attitude of moral superiority toward the mentally ill in the early 1960s, specifically in mental hospitals, has not disappeared. This was reported by Erving Goffman in his classic study. A Canadian insurance executive told a conference of physicians in May 2000 that they should look in the mirror for a picture of the ongoing stigmatization of the mentally ill. The executive was quoted as saying, "Stigma among physicians deters the detection of mental disorders, defers or pre-empts correct diagnosis and proper treatment and, by definition, prolongs suffering." An American physician who specializes in the treatment of substance addicts cites three reasons for the persistence of stigmatizing attitudes among his colleagues: their tendency to see substance abuse as a social issue, rather than a health issue; their lack of training in detecting substance abuse; and their mistaken belief that no effective treatments exist. A similar lack of information about effective treatments characterizes many psychiatrists' attitudes toward borderline personality disorder.

Stigma as cause of mental illness

It is significant that researchers in the field of social psychology have moved in recent years to analyzing stigma in terms of stress. Newer studies in this field now refer to membership in a stigmatized group as a stressor that increases a person's risk of developing a mental illness. The physiological and psychological effects of stress caused by racist behavior, for example, have been documented in African Americans. Similar studies of obese people have found that the stigmatization of obesity is the single most important factor in the psychological problems of these patients. To give still another example, the high rates of depression among postmenopausal women have been attributed to the fact that aging is a much heavier stigma for women than for men in contemporary society.

Stigma has a secondary effect on rates of mental illness in that members of stigmatized groups have less access to educational opportunities, well-paying jobs, and adequate health care. They are therefore exposed to more environmental stressors in addition to the stigma itself.

Stigma as effect

Stigma resulting from mental illness has been shown to increase the likelihood of a patient's relapse. Since a mental disorder is not as immediately apparent as race, sex, or physical handicaps, many people with mental disorders undergo considerable strain trying to conceal their condition from strangers or casual acquaintances. More seriously, the stigma causes problems in the job market, leading to stress that is related to lying to a potential employer and fears of being found out. Erving Goffman reported in the 1960s that a common way around the dilemma involved taking a job for about six months after discharge from a mental institution, then quitting that job and applying for another with a recommendation from the first employer that did not mention the history of mental illness.

The stigmatization of the patient with mental illness extends to family members, partly because they are often seen as the source of the patient's disorder. A recent editorial in the Journal of the American Medical Association tells the story of two sets of parents coping with the stress caused by other people's reactions to their children's mental illness, and the different responses they received when the children's disorders were thought to be a physical problem. The writer also tells of the problems encountered by the parents of an autistic child. The writer stated that family excursions were difficult, and continued, "My friend's wife was reprimanded by strangers for not being able to control her son. The boy was stared at and ridiculed. The inventive parent, fed up with the situation, bought a wheelchair to take the child out. The family was now asked about their child's disability. They were praised for their tolerance of his physical hardship and for their courage; the son was commended for his bravery. Same parents, same child, different view."

The results of stigma

The stigmatization of mental disorders has a number of consequences for the larger society. Patients' refusal to seek treatment, noncompliance with treatment, and inability to find work has a high price tag. Disability related to mental illness accounts for fully 15% of the economic burden caused by all diseases in developed countries.

Seeking treatment

Stigmatization of mental illness is an important factor in preventing persons with mental disorders from asking for help. This factor affects even mental health services on university campuses; interviews with Harvard students following a 1995 murder in which a depressed student killed a classmate, found that students hesitated to consult mental health professionals because many of their concerns were treated as disciplinary infractions, rather than illnesses. The tendency to stigmatize mental disorders as character faults is as prevalent among educators as among medical professionals. In addition, studies of large corporations indicate that employees frequently hesitate to seek treatment for depression and other stress-related disorders for fear of receiving negative evaluations of job performance and possible termination. These fears are especially acute during economic downturns and periods of corporate downsizing.

Compliance with treatment

Another connection between mental disorders and stigma is the low rates of treatment compliance among patients. To a large extent, patient compliance is a direct reflection of the quality of the doctor-patient relationship. One British study found that patients with mental disorders were likely to prefer the form of treatment recommended by psychiatrists with whom they had good relationships, even if the treatment itself was painful or difficult. Some patients preferred electroconvulsive therapy (ECT) to tranquilizers for depression because they had built up trusting relationships with the doctors who used ECT, and perceived the doctors who recommended medications as bullying and condescending. Other reasons for low compliance with treatment regimens are related to stigmatized side effects. Many patients, particularly women, discontinue medications that cause weight gain because of the social stigma attached to obesity in females.

Social and economic consequences

As already mentioned, persons with a history of treatment for mental disorders frequently encounter prejudice in the job market and the likelihood of long periods of unemployment; this can result in lower socioeconomic status, as well as loss of self-esteem. These problems are not limited to North America. A recent study of mental health patients in Norway, which is generally considered a progressive nation, found that the patients had difficulty finding housing as well as jobs, and were frequently harassed on the street as well as being socially isolated. In 1990, the Congress of the U.S. included mental disorders (with a few exceptions for disorders related to substance abuse and compulsive sexual behaviors) in the anti-discriminatory provisions of the Americans with Disabilities Act (ADA). As of 2002, mental disorders constitute the third-largest category of discrimination claims against employers.

Stigmatization of mental disorders also affects funding for research into the causes and treatment of mental disorders. Records of recent Congressional debates indicate that money for mental health research is still grudgingly apportioned as of 2002.

Future prospects

The stigma of mental illness will not disappear overnight. Slow changes in attitudes toward other social issues have occurred in the past three decades, giving hope to the lessening of stigma toward people with mental illness. However, limitations on indefinite economic expansion are an reason for concern. As the economic "pie" has to be divided among a larger number of groups, causing competition for public funding, persons with mental disorders will need skilled and committed advocates if their many serious needs are to receive adequate attention and help.

See also Stress

Resources

BOOKS

Goffman, Erving. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York: Anchor Books, 1961.

Goffman, Erving. Stigma: Notes on the Management of Spoiled Identity. New York: Simon and Schuster, Inc.,1963.

PERIODICALS

"AIDS Treatment Eludes Many Indians." AIDS Weekly (December 17, 2001): 10.

Britten, Nicky. "Psychiatry, Stigma, and Resistance: Psychiatrists Need to Concentrate on Understanding, Not Simply Compliance." British Medical Journal 317 (October 10, 1998): 763-764.

Corner, L., and J. Bond. "Insight and Perceptions of Risk in Dementia." The Gerontologist (October 15, 2001): 76.

Farriman, Annabel. "The Stigma of Schizophrenia" British Medical Journal 320 (February 19, 2000): 601.

Leshner, Alan I. "Taking the Stigma Out of Addiction." Family Practice News 30 (August 15, 2000): 30.

Lyons, Declan, and Declan M. McLoughlin. "Psychiatry (Recent Advances)." British Medical Journal 323 (November 24, 2001): 1228-1231.

Maher, Tracy. "Tackling the Stigma of Schizophrenia." Practice Nurse 20 (November 2000): 466-470.

Mahoney, D. "Understanding Racial/Ethnic Variations in Family's Response to Dementia." The Gerontologist (October 15, 2001): 120.

Myers, A., and J. C. Rosen. "Obesity Stigmatization and Coping: Relation to Mental Health Symptoms, Body Image, and Self-Esteem." International Journal of Obesity and Related Metabolic Disorders 23 (March 1999): 221-230.

Neil, Janice A. "The Stigma Scale: Measuring Body Image and the Skin." Plastic Surgical Nursing 21 (Summer 2001): 79.

Parker, Gordon, Gemma Gladstone, Kuan Tsee Chee. "Depression in the Planet's Largest Ethnic Group: The Chinese." American Journal of Psychiatry 158 (June 2001): 857.

Perlick, D. A., R. A. Rosenheck, J. F. Clarkin, and others. "Stigma as a Barrier to Recovery: Adverse Effects of Perceived Stigma on Social Adaptation of Persons Diagnosed with Bipolar Affective Disorder." Psychiatric Services 52 (December 2001): 1627-1632.

"Reducing the Stigma of Mental Illness." Lancet 357 (April 7, 2001): 1055.

Russell, J. M., and J. A. Mackell. "Bodyweight Gain Associated with Atypical Antipsychotics: Epidemiology and Therapeutic Implications." CNS Drugs 15 (July 2001): 537-551.

Sirey, Jo Anne, Martha L. Bruce, George S. Alexopoulos, and others. "Perceived Stigma as a Predictor of Treatment Discontinuation in Young and Older Outpatients with Depression." American Journal of Psychiatry 158 (March 2001): 479-481.

Smart, L., and D. M. Wegner. "Covering Up What Can't Be Seen: Concealable Stigma and Mental Control." Journal of Personal and Social Psychology 77 (September 1999): 474-486.

Thesen, J. "Being a Psychiatric Patient in the Community—Reclassified as the Stigmatized 'Other.'" Scandinavian Journal of Public Health 29 (December 2001): 248-255.

Weissman, Myrna M. "Stigma." Journal of the American Medical Association 285 (January 17, 2001): 261.

Wojcik, Joanne. "Campaign Seeks to Remove Stigma of Mental Illness." Business Insurance 36 (January 21,2002): 1.

Yanos, Philip T., Sarah Rosenfeld, Allan V. Horwitz. "Negative and Supportive Social Interactions and Quality of Life Among Persons Diagnosed with Severe Mental Illness." Community Mental Health Journal 37 (October 2001): 405.

ORGANIZATIONS

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA22201. (800) 950-6264. <www.nami.org>.

OTHER

National Institute of Mental Health (NIMH). The Impact of Mental Illness on Society. NIH Publication No. 01-4586. <www.nimh.nih.gov/publicat/burden.cfm>.

Office of the Surgeon General. Mental Health: A Report of the Surgeon General. Washington, D.C.: Government Printing Office, 1999. A copy of the report may be ordered by faxing the Superintendent of Documents at(202) 512-2250.

Rebecca J. Frey, Ph.D.

Stigma

Definitions

The nature of stigma

Stigma and mental illness

The results of stigma

Future prospects

Resources

Definitions

The 1999 report on mental health by the Surgeon General of the United States was regarded as a landmark document in the United Kingdom, as well as the United States. This was because of its straightforward identification of the stigma associated with mental illness as the chief obstacle to effective treatment of persons with mental disorders. Stigma (plural, stigmata) is a Greek word that in its origins referred to a kind of tattoo mark that was cut or burned into the skin of criminals, slaves, or traitors in order to visibly identify them as blemished or morally polluted persons. These individuals were to be avoided or shunned, particularly in public places. The word was later applied to other personal attributes that are considered shameful or discrediting.

Social psychologists have distinguished three large classes, or categories, of stigma:

• Physical deformities. These include extremes of height and weight and such conditions as albinism and facial disfigurements or missing limbs. In the developed countries, this category also includes such signs of aging as gray hair, wrinkles, and stooped posture.
• Weaknesses or defects of individual character. This category includes biographical data that are held to indicate personal moral defect, such as a criminal record, addiction, divorce, treatment for mental illness, unemployment, suicide attempts, etc.
• Tribal stigma. This type of stigma refers to a person’s membership in a race, ethnic group, religion, or (for women) gender that is thought to disqualify all members of the group.

The nature of stigma

Origins

One explanation for the origin of stigmata is that its roots in the human being’s concern for group survival at earlier times in their evolutionary journey. According to this theory, stigmatizing people who were perceived as unable to contribute to the group’s survival, or who were seen as threats to its well-being, were stigmatized in order to justify being forced out or being isolated.

The group survival theory is also thought to explain why certain human attributes seem to be universally regarded as stigmata, while others are specific to certain cultures or periods of history. Mental illness appears to be a characteristic that has nearly always led to the stigmatization and exclusion of its victims. The primary influences on Western culture, the classical philosophical tradition of Greece and Rome, and the religious traditions of Judaism and Christianity indicate that mental illness was a feared affliction that carried a heavy stigma. The classical philosopher’s definition of a human being as a “rational animal” excluded he/she who had lost the use of reason was no longer regarded as fully human; most likely he or she was under a divine curse. This attitude was summarized in the well-known saying of Lucretius, “Whom the gods wish to destroy, they first make mad.”

In the Bible, both the Old and the New Testaments reflect the same fear of mental illness. In 1 Samuel 21, there is an account of David’s pretending to be insane in order to get away from the king of a neighboring territory. “He changed his behavior before [the king’s servants]; he pretended to be mad in their presence. He scratched marks on the doors of the gate, and let his spittle run down his beard.” The king, who was taken in by an act that certainly fits the Diagnostic and Statistical Manual of Mental Disorders criteria for malingering , quickly sent David on his way. In the New Testament, one of Jesus’ most famous miracles of healing (Mark 5:1-20) is the restoration of sanity to a man so stigmatized by his village that he was hunkered down in the graveyard (itself a stigmatized place) outside the village when Jesus met him. Mark’s account also notes that the villagers had tried at different times to chain or handcuff the man because they were so afraid of him. One important positive contribution of Biblical heritage, however, is a sense of religious obligation toward the mentally ill. Among Christians, the New Testament’s account of Jesus’ openness to all kinds of stigmatized people—tax collectors, prostitutes, and physically deformed people, as well as the mentally ill—became the basis for the establishment of the first shelters and hospitals for the mentally ill.

Contemporary contexts

The core feature of stigma in the modern world is defined by social psychologists as the possession of an attribute“that conveys a devalued social identity within a particular context.” Context is important in assessing the nature and severity of stress that a person suffers with regard to stigma. Certain attributes, such as race or sex, affect an individual’s interactions with other people in so many different situations that they have been termed “master status” attributes. These have become the classic identifying characteristic of the person who possesses them. Dorothy Sayers’ essay, “Are Women Human?” is not only a witty satire on the way men used to describe a woman’s job or occupation (with constant reference to feminine qualities), but a keen social analysis of the problems created by master status attributes for persons who are stigmatized.

Other forms of devalued social identity are relative to specific cultures or subcultures. In one social context, a person who is stigmatized for an attribute devalued by a particular group may find acceptance in another group that values the particular attribute. A common example is that of an artistically or athletically talented child who grows up in a family that values only intellectual accomplishment. When the youngster is old enough to leave the family of origin, he or she can find a school or program for other students who share the same interest. A less marked contrast, but one that is relevant to the treatment of mental illness, is the cultural differences with regard to the degree of response to certain symptoms of mental illness. A study conducted in the early 2000s assessed the reaction of family members to elderly people who were diagnosed with Alzheimer’s disease (AD). Findings pointed to considerable variation across racial and ethnic groups. Asian Americans were most affected by feelings of shame and social stigma relative to the memory loss of a family member, while African Americans were the least affected.

One additional complicating feature of stigma is the issue of overlapping stigmata. Many people belong to several stigmatized groups or categories, and it is not always easy to determine which category triggers the unkind or discriminatory treatment encountered. For example, one study of the inadequate medical treatment that is offered to most HIV-positive Native Americans noted that the stigma of Acquired Immune Deficiency Syndrome (AIDS) provides a strong motivation for not seeking treatment. The study protocol, however, did not seek to investigate whether young Native American men are afraid of being stigmatized for their sexual orientation, their race, their low socio-economic status, or all three.

Stigma and mental illness

Stigma and specific disorders

The stigma that is still attached to mental illness in the developed countries does not represent a simple or straightforward problem. Public health experts who have studied the stigmatization of mental illness in recent years have noted that the general public’s perception of mental illness varies, depending on the nature of the disorder. While in general the stigma of mental illness in contemporary society is primarily associated with the second of the three categories of stigma listed above,—supposed character failings—it also spills over into the first category. Mental disorders that affect a person’s physical appearance— particularly weight gain—are more heavily stigmatized than those that do not.

The stigma related to certain types of mental disorders has declined since the 1950s, most notably in regard to depression and the anxiety disorders . It is thought that the reason for this change is that people are more likely nowadays to attribute these disorders to stress, with which most people can identify. On the other hand, the stigma associated with psychotic disorders appears to be worse than it was in the 1950s. Changes in public attitude are also reflected in age-group patterns in seeking or dropping out of treatment for mental disorders. One study demonstrated that older adults being treated for depression were more likely than younger adults to drop out of treatment because they felt stigmatized. The difference in behavior is related to public attitudes toward mental illness that were widespread when the older adults were adolescents.

In 2002, the types of mental disorders that carry the heaviest stigma fall into the following categories:

• Disorders associated in the popular mind with violence and/or illegal activity. These include schizophrenia, mental problems associated with HIV infection, and substance abuse disorders.
• Disorders in which the patient’s behavior in public may embarrass family members. These include dementia in the elderly, borderline personality disorder in adults, and the autistic spectrum disorders in children.
• Disorders treated with medications that cause weight gain or other visible side effects.

The role of the media

The role of the media in perpetuating the stigma-tization of mental illness has received increasing attention from public health researchers, particularly in Great Britain. In 1998, the Royal College of Psychiatrists launched a five-year campaign intended to educate the general public about the nature and treatment of mental illness. Surveys conducted among present and former mental patients found that they considered media coverage of their disorders to be strongly biased toward the sensational and the negative. One-third of patients said that they felt more depressed or anxious as a result of news stories about the mentally ill, and 22% felt more withdrawn. The main complaint from mental health professionals, as well as patients, is that the media presented mentally ill people as “dangerous time bombs waiting to explode” when in fact 95% of murders in the United Kingdom are committed by people with no mental illness. The proportion of homicides committed by the mentally ill has decreased by 3% per year since 1957, but this statistic goes unre-ported. Much the same story of unfair stigmatization in the media could be told in the United States, as the Surgeon General’s report indicates.

Physicians’ attitudes toward mental illness

Physicians’ attitudes toward the mentally ill are also increasingly recognized as part of the problem of stigmatization. The patronizing attitude of moral superiority toward the mentally ill in the early 1960s, specifically in mental hospitals, has not disappeared.

This was reported by Erving Goffman in his classic study. A Canadian insurance executive told a conference of physicians in May 2000 that they should look in the mirror for a picture of the ongoing stigmatization of the mentally ill. The executive was quoted as saying, “Stigma among physicians deters the detection of mental disorders, defers or pre-empts correct diagnosis and proper treatment and, by definition, prolongs suffering.” An American physician who specializes in the treatment of substance addicts cites three reasons for the persistence of stigmatizing attitudes among his colleagues: their tendency to see substance abuse as a social issue, rather than a health issue; their lack of training in detecting substance abuse; and their mistaken belief that no effective treatments exist. A similar lack of information about effective treatments characterizes many psychiatrists’ attitudes toward borderline personality disorder.

Stigma as cause of mental illness

It is significant that researchers in the field of social psychology have moved in recent years to analyzing stigma in terms of stress. Newer studies in this field now refer to membership in a stigmatized group as a stressor that increases a person’s risk of developing a mental illness. The physiological and psychological effects of stress caused by racist behavior, for example, have been documented in African Americans. Similar studies of obese people have found that the stigmatization of obesity is the single most important factor in the psychological problems of these patients. To give still another example, the high rates of depression among postmenopausal women have been attributed to the fact that aging is a much heavier stigma for women than for men in contemporary society.

Stigma has a secondary effect on rates of mental illness in that members of stigmatized groups have less access to educational opportunities, well-paying jobs, and adequate health care. They are therefore exposed to more environmental stressors in addition to the stigma itself.

Stigma as effect

Stigma resulting from mental illness has been shown to increase the likelihood of a patient’s relapse . Since a mental disorder is not as immediately apparent as race, sex, or physical handicaps, many people with mental disorders undergo considerable strain trying to conceal their condition from strangers or casual acquaintances. More seriously, the stigma causes problems in the job market, leading to stress that is related to lying to a potential employer and fears of being found out. Erving Goffman reported in the 1960s that a common way around the dilemma involved taking a job for about six months after discharge from a mental institution, then quitting that job and applying for another with a recommendation from the first employer that did not mention the history of mental illness.

The stigmatization of the patient with mental illness extends to family members, partly because they are often seen as the source of the patient’s disorder. A recent editorial in the Journal of the American Medical Association tells the story of two sets of parents coping with the stress caused by other people’s reactions to their children’s mental illness, and the different responses they received when the children’s disorders were thought to be a physical problem. The writer also tells of the problems encountered by the parents of an autistic child. The writer stated that family excursions were difficult, and continued, “My friend’s wife was reprimanded by strangers for not being able to control her son. The boy was stared at and ridiculed. The inventive parent, fed up with the situation, bought a wheelchair to take the child out. The family was now asked about their child’s disability. They were praised for their tolerance of his physical hardship and for their courage; the son was commended for his bravery. Same parents, same child, different view.”

The results of stigma

The stigmatization of mental disorders has a number of consequences for the larger society. Patients’ refusal to seek treatment, noncompliance with treatment, and inability to find work has a high price tag. Disability related to mental illness accounts for fully 15% of the economic burden caused by all diseases in developed countries.

Seeking treatment

Stigmatization of mental illness is an important factor in preventing persons with mental disorders from asking for help. This factor affects even mental health services on university campuses; interviews with Harvard students following a 1995 murder in which a depressed student killed a classmate, found that students hesitated to consult mental health professionals because many of their concerns were treated as disciplinary infractions, rather than illnesses. The tendency to stigmatize mental disorders as character faults is as prevalent among educators as among medical professionals. In addition, studies of large corporations indicate that employees frequently hesitate to seek treatment for depression and other stress-related disorders for fear of receiving negative evaluations of job performance and possible termination. These fears are especially acute during economic downturns and periods of corporate downsizing.

Compliance with treatment

Another connection between mental disorders and stigma is the low rates of treatment compliance among patients. To a large extent, patient compliance is a direct reflection of the quality of the doctor-patient relationship. One British study found that patients with mental disorders were likely to prefer the form of treatment recommended by psychiatrists with whom they had good relationships, even if the treatment itself was painful or difficult. Some patients preferred electroconvulsive therapy (ECT) to tranquilizers for depression because they had built up trusting relationships with the doctors who used ECT, and perceived the doctors who recommended medications as bullying and condescending. Other reasons for low compliance with treatment regimens are related to stigmatized side effects. Many patients, particularly women, discontinue medications that cause weight gain because of the social stigma attached to obesity in females.

Social and economic consequences

As already mentioned, persons with a history of treatment for mental disorders frequently encounter prejudice in the job market and the likelihood of long periods of unemployment; this can result in lower soci-oeconomic status, as well as loss of self-esteem. These problems are not limited to North America. A recent study of mental health patients in Norway, which is generally considered a progressive nation, found that the patients had difficulty finding housing as well as jobs, and were frequently harassed on the street as well as being socially isolated. In 1990, the Congress of the U.S. included mental disorders (with a few exceptions for disorders related to substance abuse and compulsive sexual behaviors) in the anti-discriminatory provisions of the Americans with Disabilities Act (ADA). As of 2002, mental disorders constitute the third-largest category of discrimination claims against employers.

Stigmatization of mental disorders also affects funding for research into the causes and treatment of mental disorders. Records of recent Congressional debates indicate that money for mental health research is still grudgingly apportioned as of 2002.

Future prospects

The stigma of mental illness will not disappear overnight. Slow changes in attitudes toward other social issues have occurred in the past three decades, giving hope to the lessening of stigma toward people with mental illness., However, limitations on

KEY TERMS

Stigma —A mark or characteristic trait of a disease or defect; by extension, a cause for reproach or a stain on one’s reputation.

indefinite economic expansion are an reason for concern. As the economic “pie” has to be divided among a larger number of groups, causing competition for public funding, persons with mental disorders will need skilled and committed advocates if their many serious needs are to receive adequate attention and help.

See alsoStress.

Resources

BOOKS

Goffman, Erving. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York: Anchor Books, 1961.

Goffman, Erving. Stigma: Notes on the Management of Spoiled Identity. New York: Simon and Schuster, Inc., 1963.

PERIODICALS

“AIDS Treatment Eludes Many Indians.” AIDS Weekly (December 17, 2001): 10.

Britten, Nicky. “Psychiatry, Stigma, and Resistance: Psychiatrists Need to Concentrate on Understanding, Not Simply Compliance.” British Medical Journal 317 (October 10, 1998): 763-764.

Corner, L., and J. Bond. “Insight and Perceptions of Risk in Dementia.” The Gerontologist (October 15, 2001): 76.

Farriman, Annabel. “The Stigma of Schizophrenia” British Medical Journal 320 (February 19, 2000): 601.

Leshner, Alan I. “Taking the Stigma Out of Addiction.” Family Practice News 30 (August 15, 2000): 30.

Lyons, Declan, and Declan M. McLoughlin. “Psychiatry (Recent Advances).” British Medical Journal 323 (November 24, 2001): 1228-1231.

Maher, Tracy. “Tackling the Stigma of Schizophrenia.” Practice Nurse 20 (November 2000): 466-470.

Mahoney, D. “Understanding Racial/Ethnic Variations in Family’s Response to Dementia.” The Gerontologist (October 15, 2001): 120.

Myers, A., and J. C. Rosen. “Obesity Stigmatization and Coping: Relation to Mental Health Symptoms, Body Image, and Self-Esteem.” International Journal of Obesity and Related Metabolic Disorders 23 (March 1999): 221-230.

Neil, Janice A. “The Stigma Scale: Measuring Body Image and the Skin.” Plastic Surgical Nursing 21 (Summer 2001): 79.

Parker, Gordon, Gemma Gladstone, Kuan Tsee Chee. “Depression in the Planet’s Largest Ethnic Group: The Chinese.” American Journal of Psychiatry 158 (June 2001): 857.

Perlick, D. A., R. A. Rosenheck, J. F. Clarkin, and others. “Stigma as a Barrier to Recovery: Adverse Effects of Perceived Stigma on Social Adaptation of Persons Diagnosed with Bipolar Affective Disorder.” Psychiatric Services 52 (December 2001): 1627-1632.

“Reducing the Stigma of Mental Illness.” Lancet 357 (April 7, 2001): 1055.

Russell, J. M., and J. A. Mackell. “Bodyweight Gain Associated with Atypical Antipsychotics: Epidemiology and Therapeutic Implications.” CNS Drugs 15 (July 2001): 537-551.

Sirey, Jo Anne, Martha L. Bruce, George S. Alexopoulos, and others. “Perceived Stigma as a Predictor of Treatment Discontinuation in Young and Older Outpatients with Depression.” American Journal of Psychiatry 158 (March 2001): 479-481.

Smart, L., and D. M. Wegner. “Covering Up What Can’t Be Seen: Concealable Stigma and Mental Control.” Journal of Personal and Social Psychology 77 (September 1999): 474-486.

Thesen, J. “Being a Psychiatric Patient in the Community— Reclassified as the Stigmatized ‘Other.”’ Scandinavian Journal of Public Health 29 (December 2001): 248-255.

Weissman, Myrna M. “Stigma.” Journal of the American Medical Association 285 (January 17, 2001): 261.

Wojcik, Joanne. “Campaign Seeks to Remove Stigma of Mental Illness.” Business Insurance 36 (January 21, 2002): 1.

Yanos, Philip T., Sarah Rosenfeld, Allan V. Horwitz. “Negative and Supportive Social Interactions and Quality of Life Among Persons Diagnosed with Severe Mental Illness.” Community Mental Health Journal 37 (October 2001): 405.

ORGANIZATIONS

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201. (800) 950-6264. www.nami.org

OTHER

National Institute of Mental Health (NIMH). The Impact of Mental Illness on Society. NIH Publication No. 01-4586. www.nimh.nih.gov/publicat/burden.cfm

Office of the Surgeon General. Mental Health: A Report of the Surgeon General. Washington D.C.: Government Printing Office, 1999. A copy of the report may be ordered by faxing the Superintendent of Documents at (202) 512-2250.

Rebecca J. Frey, Ph.D.

Stigma

IMPACT OF STIGMA ON ITS TARGETS

WHAT LEADS PEOPLE TO STIGMATIZE OTHERS?

BIBLIOGRAPHY

Although the term originally described a mark made through branding to designate a person of undesirable moral character, stigma was introduced into the psychological literature by Erving Goffman in 1963 to refer more broadly to any attribute or characteristic that makes its bearer tainted or devalued by others. Jennifer Crocker, Brenda Major, and Claude M. Steele (1998) refined the definition, noting that stigmatized characteristics convey “a social identity that is devalued in a particular social context” (p. 505). This definition highlights two important properties of stigma. The first is that the stigmatized characteristic is attributed meaning beyond the characteristic itself—it is often assumed to be broadly reflective of the person or his or her identity. The second property is that personal characteristics lead to stigma through their context-specific symbolic value, rather than through inherent properties of their own. Wrinkles and white hair, for example, may be revered as a sign of wisdom and experience when it comes to relationship advice, but may lead to undeserved assumptions of incompetence when it comes to navigating computers.

Goffman distinguished among three types of stigmas: tribal stigmas (e.g., racial, ethnic stigmas), blemishes of individual character (e.g., drug addict, criminal offender), and abominations of the body (e.g., weight, body scars). Despite enjoying wide recognition, Goffman’s typological approach has given way to a more dimensional approach to stigma, one relying more on general principles that help understand the underlying differences and commonalities among stigmas. In 1984 Edward E. Jones and colleagues proposed six such dimensions: degree of concealability, degree of change over time, degree of disruptiveness, how aesthetic others find the attribute, how the stigma originates, and degree of peril the stigma poses.

IMPACT OF STIGMA ON ITS TARGETS

The psychological impact of these dimensions, particularly concealability and responsibility, has been a topic of intense study. Research on the dimension of responsibility in particular has shed light on the internalization hypothesis —the notion that people internalize society’s negative ascriptions about their group, with negative consequences for their self-concept. Early studies included Kenneth B. and Mamie P. Clark’s 1947 doll study, which found that young African American children preferred to play with white dolls rather than black dolls. Although the children’s responses may have stemmed from their efforts to please the researchers or an unfamiliarity with black dolls, the findings were widely interpreted as evidence for the deleterious effects of stigma on the self-concept.

This interpretation remains popular despite empirical evidence to the contrary. Research consistently shows that the self-esteem of African Americans is, on average, higher than the self-esteem of U.S. whites. In 1989 Crocker and Major proposed that stigmatization may actually protect self-esteem, such that when people know they are the targets of stigma, negative outcomes can be attributed to the prejudice of others rather than to one’s talents or efforts (thereby protecting self-esteem). Nevertheless, attributions to prejudice are protective only to the extent that people believe that they are not to blame or that the prejudice is undeserved. For example, overweight women, when rejected on the basis of their weight, nevertheless show a drop in self-esteem, presumably because they endorse the notion that weight is controllable and a matter of willpower. Thus perceptions of responsibility/controllability may influence the impact of stigma on the self. A thus-far unresolved puzzle is whether and how stigma affects the self-esteem of Asian Americans, Latinos, and Native Americans in the United States, who show lower self-esteem than U.S. whites.

Importantly, one does not need to believe or internalize relevant stereotypes in order for them to have adverse consequences. This is evident from research on stereotype threat, which shows that performance (e.g., on tests) is affected following the mere awareness that one might be viewed or judged according to a stereotype. For example, whereas women underperform relative to men in a math task when reminded about gender differences, performance differences disappear when the same task is framed as gender-neutral—that is, when the threat is removed. These data, also replicated among stigmatized minorities in the academic domain, are powerful demonstrations against nativist views of performance differences. Subsequent research shows that the cognitive and emotional disruption of having to contend with stereotypes plays a critical role in explaining group-based performance differences where stereotypes are involved.

Individuals may use a variety of strategies to cope with the threat of stigmatization. Behaviorally, people may avoid situations or contexts in which a particular identity is devalued. Psychologically, individuals may disengage, and ultimately disidentify, from the domain in which their group is stigmatized. Proactive strategies may include efforts to disprove the stereotype, as well as social activism. Thus, people are not merely passive recipients of social judgments and evaluations, but rather they psychologically construe and physically shape their social worlds to actively cope with the problem of stigma.

WHAT LEADS PEOPLE TO STIGMATIZE OTHERS?

Approaches to stigmatization from the perceiver’s perspective have a longer history and fall into two broad approaches: motivational and cognitive. They both encompass stereotypes, prejudice, and discrimination, terms that roughly correspond respectively to beliefs, attitudes, and behavior. The cognitive approach conceptualizes stigmatization as a by-product of human information-processing biases. The basis for this approach is that people naturally use schemas, or mental categories, to reduce the potentially limitless number of stimuli in the world into more manageable groupings. Schemas provide not only an organizing principle to help individuals navigate the world, but also a way for people to “fill in the blanks” as needed: A person assumes a new chair will have the properties to support his or her weight, even though the person has never sat on it. According to the cognitive approach, similar processes apply when a person stigmatizes others: A person may assume, for example, that a new female acquaintance cannot read a map though the former has no experience or information on this woman’s map skills. Despite being unfair or even harmful to the perceived (by eliciting stereotype threat, for example), these cognitive processes perpetuate stigma because they confer to the perceiver the benefit of having to use relatively few mental resources. Further, some mental associations may be relatively automatic, that is, outside of awareness, so that even people who are motivated to be egalitarian and sincerely believe they are not prejudiced can stigmatize others unwittingly.

By contrast, the central idea behind the motivational approach is that people stigmatize others to feel better about themselves. Research shows that individuals receiving negative feedback about themselves are more likely to discriminate against stigmatizable others, and that this restores self-esteem. Existentially oriented work proposes that people use symbolic means, including a deep investment in cultural or societal ideals, to transcend death. Thus, when reminded of their mortality, people are more likely to be less tolerant of others who subscribe to different worldviews (e.g., religion, political orientations). Newer views suggest that specific intergroup attitudes and behavior depend on the amount of intergroup competition as well as the group’s perceived status. A high-status group that one competes for resources with, for example, tends to be viewed as competent and cold, eliciting envy. By contrast, a low-status group that does not represent a competitive threat tends to be seen as incompetent and warm, eliciting pity. Thus the field is moving toward identifying specific emotions and attitudes associated with different manifestations of stigma. Together with an increasing volume of research identifying processes related to being the target of stigma, the field is moving toward a more precise, balanced science.

SEE ALSO Clark, Kenneth B.; Discrimination; Goffman, Erving; Prejudice; Racism; Stereotype Threat; Stereotypes

BIBLIOGRAPHY

Clark, Kenneth B., and Mamie P. Clark. 1947. Racial Identification and Preference in Negro Children. In Readings in Social Psychology, eds. Theodore M. Newcomb and Eugene L. Hartley, 169–178. New York: Holt.

Crocker, Jennifer, and Brenda Major. 1989. Social Stigma and Self-Esteem: The Self-Protective Properties of Stigma. Psychological Review 96 (4): 608–630.

Crocker, Jennifer, Brenda Major, and Claude M. Steele. 1998. Social Stigma. In The Handbook of Social Psychology, 4th ed., eds. Daniel T. Gilbert and Susan T. Fiske, 504–553. Boston: McGraw-Hill.

Goffman, Erving. 1963. Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, NJ: Prentice-Hall.

Jones, Edward E., Amerigo Farina, Albert H. Hastorf, et al. 1984. Social Stigma: The Psychology of Marked Relationships. New York: Freeman.

Kunda, Ziva. 1999. Social Cognition: Making Sense of People. Cambridge, MA: MIT Press.

Steele, Claude M. 1997. A Threat in the Air: How Stereotypes Shape Intellectual Identity and Performance. American Psychologist 52 (6): 613–629.

Twenge, Jean M., and Jennifer Crocker. 2002. Race and Self-Esteem: Meta-analyses Comparing Whites, Blacks, Hispanics, Asians, and American Indians and Comment on Gray-Little and Hafdahl (2000). Psychological Bulletin 128 (3): 371–408.

Rodolfo Mendoza-Denton

stig·ma / ˈstigmə/ • n. (pl. stig·mas or esp. in sense 2 stig·ma·ta / stigˈmätə; ˈstigmətə/ ) 1. a mark of disgrace associated with a particular circumstance, quality, or person: the stigma of mental disorder to be a nonreader carries a social stigma.2. (stigmata) (in Christian tradition) marks corresponding to those left on Jesus’ body by the Crucifixion, said to have been impressed by divine favor on the bodies of St. Francis of Assisi and others.3. Med. a visible sign or characteristic of a disease. ∎  a mark or spot on the skin.4. Bot. (in a flower) the part of a pistil that receives the pollen during pollination.ORIGIN: late 16th cent. (denoting a mark made by pricking or branding): via Latin from Greek stigma ‘a mark made by a pointed instrument, a dot’; related to stick¹ .

609. Stigma

1. mark of Cain God’s mark on Cain, a sign of his shame for fratricide. [O. T.: Genesis 4:15]
2. scarlet letter the letter “A” for “adultery” sewn on Hester Prynne’s garments. [Am. Lit.: Hawthorne The Scarlet Letter ]