Understanding Stigma

Understanding stigma

Jessica Macdonald

Defining stigma

Much of the literature which seeks to conceptualise stigma takes as its starting point the definition proposed by Goffman in his seminal 1963 paper:

Stigma…is the situation of the individual who is disqualified from full social acceptance. (Goffman, 1963: preface)

This definition has retained its relevance throughout the years of further study and Goffman’s assertion that a person who is stigmatized against is “reduced in our minds from a whole and usual person to a tainted, discounted one” Goffman, 1963: 3) rings equally true. It is important to note that stigma occurs within a social context and that, while experiencing or possessing a stigmatized trait may be associated with discretisation in the minds of others, it may or may not reflect upon the value or worth of person experiencing it. It may be useful at this point to draw distinctions between the concepts of stigma and discrimination. Stigma concerns attitudes and implicit emotional reactions towards people who possess the characteristic which has been labelled as undesirable whereas discrimination refers to the behavioural and physical manifestation of these attitudes. Discrimination is therefore the enactment of stigmatising beliefs. These terms will be used in this way throughout this review.

Types of stigma

The dominant model of stigma utilised within the literature which conceptualises stigma is that proposed by Pryor and Reeder (2011). They suggest that stigma is the result of a complex interaction among individual, interpersonal and social factors including Their model comprises structural stigma, public stigma, stigma by association and self-stigma to bring together the literature and provide a holistic overview of stigma. Pryor and Reeder’s four types of stigma are interrelated and public stigma is perceived to be central to the manifestation of the three other types (Figure 1). These stigma types are explained further below.

Public stigma

Public stigma refers to the negative emotional reactions of individuals towards those who they perceive to hold a stigmatized condition. These negative reactions may prompt an individual to change their behaviour towards a stigmatised person in a number of ways such as avoidance behaviour, aversion to interaction, projecting stereotypical characteristicsonto someone perceived to have a stigmatized condition and treating that person as if their skills and experiences are less valid and important. The level of stigma felt by a person with lived experience of a specific condition is associated with a number of factors. One such factor is the extent to which an individual is perceived to be personally responsible for their condition (onset controllability). The perceived severityof the condition and the perceived dangerousnessof the person who experiences that condition are also associated with the levels of stigma expressed. Reaction to a stigmatized individual or condition can be thought of as a dual-process of implicit and explicit reactions. An immediate implicit reaction such as pity or fear can be tempered by explicit reactions shaped by knowledge about the condition or further contact with the individual. However, stigmatizing implicit reactions can be further exacerbated by agreement with stereotypes shaped by negative media coverage of people with stigmatized conditions, for example (Bos et al, 2013).

Stigma by association

Stigma by association is the stigma experienced by an individual as a result of their relationship with a person who experiences a stigmatized condition. This is thought to occur most commonly when the individual is a related to the person experiencing the stigmatized condition. However, some research into this area suggests that proximity alone – eg. sitting beside someone with a stigmatised condition in the workplace – is enough for associated stigma to be experienced. Stutterheim et al (2009) found that family members of stigmatized individuals may encourage them to conceal their condition. This may have a detrimental effect on the psychological wellbeing of the individual.

Structural stigma

Structural stigma refers to the ways in which stigma is perpetuated and exacerbated by social ideologies and institutions. In terms of mental health stigma, this may be enacted though inequalities and lack of parity of esteem for people with mental health conditions. Examples of structural stigma could be funding cuts to mental health services, high unemployment rates among people with lived experience of mental ill-health or predominantly negative media coverage of stories relation to mental health (Corrigan, Markowitz and Watson, 2004).

Self-stigma

Public stigma, structural and associated stigmas can impact upon the self as a result of actual experiences of stigma and discrimination. Perceived stigma, whereby individuals anticipate that they will experience stigma or discrimination (Bos et al, 2013), also has significant negative impacts on the self. Self-stigma occurs when people who experience a stigmatized condition internalise the stigma expressed towards that condition in the public sphere and apply it to their own belief set and behaviour. Corrigan and Rao (2013) propose that this internalisation of stigma occurs in a series of stages, starting with an awareness of public stigma, agreement with that stigma, application of that stigma to themselves, finally leading to harms to the self, such as self-imposed isolation and withdrawal from society (Figure 2).

Figure 2 - The stage model of self-stigma (Corrigan and Rao, 2013)

The ‘why try’effect proposed by Corrigan and Rao (2013)is an extensionof Modified Labelling Theory (Link et al, 1989). Labelling theory asserts that labelling individuals with, for example, a diagnosis of mental illness, may affect their behaviour and sense of self. Modified labelling theory examines stigma from the perspective of those who are stigmatised and focuses on their experiences (Link at al, 1989). Link and colleagues claim that individuals who experience mental ill health construct a set of beliefs about the way in which society views those who are mentally ill. The belief that those who experience mental health conditions are generally stigmatised against by the general public can lead to behaviour modifications such as secrecy and withdrawal from social support networks, which can limit self-esteem and recovery outcomes.

The why try effect asserts that that self-stigma results in life limitation, worsening recovery outcomes and decreasing self-worthamongst individuals who experience mental health conditions. A small study carried out in Scotland into self-stigma suggested that around 60% of those who experience a mental health condition also experience self-stigma. The reasons as to why some individuals experience self-stigma and some do not are not currently known (Dunion and McCarthy, 2012).Belief in one’s ability to achieve what one sets out to do, empowerment and “coming out” about one’s mental health problems are thought to be effective in reducing self-stigma.

Stigma and power

Link and Phelan (2004) theorise that stigma occurs when a number of interrelated components come together. Their model of the components of stigma places particular importance on the concept of dependence of stigma on power. According to their model, stigma only exists in cases where the stigmatizing group has the social, economic or political power to inflict seriously discriminatory consequences upon others as a result of their stigmatising beliefs. Empowering individuals who experience mental health conditions to address stigma and discrimination where they see if and acknowledging the value of experiential knowledge in planning mental health services may help to redress the power imbalance.

Link and Phellan’s (2001) model comprises an additional five components.Labelling occurs when a name is given to some socially relevant difference between people. Labelling has both positive and negative association in terms of mental health. In terms of diagnosis, labelling allows access to mental health services and can act to legitimise an individual’s feelings. Labelling may permit the individual to identify with a particular group, which can increase social support and stigma resistance (Crabtree et al, 2010). However, Link and Phelan (2004) argue that labelling or difference is an integral component of stigma.

Stereotyping results from the association of this label with undesirable characteristics e.g. dangerousness or unpredictability. These labels can then become a basis for separating one group from another. Emotional reactions play an important and underexplored part in the development of stigma. These emotional reactions can lead an individual to exhibit certain behaviour towards an individual with a stigmatised condition such as avoidance of eye contact or speaking with a lowered voice. When individuals are set apart of the basis of a perceived difference, they can experience status loss and devaluation at the hands of others. This can be enacted though discrimination at the individual or structural level and causes harm to those who experience it.

Harms of stigma

Campaigns which seek to tackle stigma and discrimination have, at their heart, an appreciation of the negative effect that stigma has on the lives of those who experience it. Stigma is a problem which is almost ubiquitous to those who experience mental health conditions. Data from the Time to Change project in England shows that 88% of mental health service users experienced one or more instanced of discrimination in 2011 (Corker et al, 2013). Literature which explores the life limiting effects that stigma can have on individuals who experience mental health problems offers some insight into the harm that can occur. In general, this literature tends to use perceived stigma as its measure; that is the extent to which people think that the general public holds stigmatizing beliefs towards those with mental health conditions.

Stigma has been shown to be associated with lowered self-esteem, psychological wellbeing and life satisfaction in those who experience it. Stigmatised individuals may resort to coping strategies such as secrecy or social withdrawal and anticipated stigma is related to demoralization, lower income, unemployment and restricted social networks with a life-limiting effect (Link et al, 2001; Markowitz, 1998).

Perceived mental health stigma has the additional harmful effect of preventing individuals from seeking help for their mental health. This is particularly the case among young people, men, ethnic minorities and individuals who have served with the armed forces (Clement et al, 2014). Stigma perceived by individuals with mental health conditions or even by the care givers can have a detrimental effect on treatment adherence (Sirey et al, 2001; Sher at al, 2005) and can constitute a barrier to recovery (Perlick et al, 2001). The harmful effects have been found to endure over time and to remain even in the absence of symptoms of a mental health condition (Link et al, 1997; Markowitz, 1998).

Implications for See Me

The extent to which individuals who experience mental health conditions experience stigma and discrimination within Scotland is not well evidence. The limited empirical literature which addresses the scale and nature of stigma within Scotland will be reviewed in the fourth paper in this series. The paucity of contemporary research which explores levels and experiences of stigma within Scotland presents an opportunity for the See Me programme to be involved in the creation and capture of evidence.

There are a number of ways in which the literature surrounding stigma can help to direct the See Me programme. Identifying specific areas and instances of public and structural stigma could be helpful in highlighting priority areas for See Me programme activity and indicators for these. In addition to those already experiencing mental health conditions, See Me should prioritise activities tagateed at those most at risk of developing mental health condition including minority groups who experience other forms of inequality and discrimination such as LGBT and BME groups.

With regards to the role of power in stigma, empowering individuals with lived experience of mental health problems to redress the power balance and challenge instances in which the encounter instances of stigma and discrimination is of great importance. Reducing self-stigma by supporting individuals to become involved in See Me activities may be of critical importance in achieving this empowerment.

By working to reduce stigma and discrimination, the See Me programme and those who undertake activities involved with it will be acting to improve recovery outcomes for individuals with experience of mental health conditions.

References

Bos, A.E.R., Pryor, J.B., Reeder, G.D. and Stutterheim, S.E. (2013) Stigma: Advances in Theory and Research. Basic and Applied Social Psychology 35(1), pp 1-9

Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, s., Bezborodovs, N., Morgan, C., Rusch, N., Brown, J.S.L. and Thornicroft, G. (2014) What is the impact if mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine [Online preview]

Corker, E., Hamilton, S., Henderson, C., Weeks, C., Pinfold, V., Rose, D., Williams, P., Flach, C., Gill, V., Lewis-Holmes, E. and Thornicroft, G. (2013) Experiences of discrimination among people using mental health services in England 2008-2011. British Journal of Psychiatry 202, pp 58-63

Corrigan, P.W., Markowitz, F.E. and Watson, A.C. (2004) Structural Levels of Mental Illness Stigma and Discrimination. Schizophrenia Bulletin 30(3).

Crabtree, J.W., Haslam, S.A., Postmes, T. and Haslam, C. (2010) Mental Health Support Groups, Stigma and Self-esteem: Positive and Negitive Implications of Group Identification. Journal of Social Issues 66(3), pp 553-569.

Dunion, L. and McCarthy, A. (2012) Pushing back: A pilot study on self stigma in Scotland.

Link B, Cullen F, Struening E, et al. (1989) A Modified Labeling Theory Approach to Mental Disorders: An Empirical Assessment American Sociological Review. 54(3):400–423.

Link, B.G., Struening, E.L., Rahav, M., Phelan, J.C. and Nuttbrock, L. (1997) On Stigma and Its Consequences: Evidence from a Longitudinal Study of Men with Dual Diagnoses of Mental Illness and Substance Abuse. Journal of Health and Social Behaviour 38(2), pp 177-190.

Link, B.G., Struening, E.L., Nesse-Todd, S., Asmussen, S. and Phelan, J.C. (2001) The Consequences of Stigma for the Self-Esteem of People With Mental Illnesses. Psychiatric Servies 52(12), pp 1621-1626

Link, B.G. and Phelan, J.C. Conceptualizing stigma. (2001) Annual Review of Sociology 27, pp 363-385

Markowitz, F.E. (1998) The Effects of Stigma on the Psychological Well-Being and Life-Satisfaction of Persons with Mental Illness. Journal of Health and Social Behaviour 39(4), pp 335-347

Perlick, D.A., Rosenheck, R.A., Clarkin, J.F., Sirey, J.A., Salahi, J., Stuening, E.L. and Link, B.G. (2001) Stigma as a Barrier to Recovery: Adverse Effects of Perceived Stigma on Social Adaptation of Persons Diagnosed with Bipolar Affective Disorder. Psychiatric Services 52(12).

Pryor, J. B., & Reeder, G. D. (2011). HIV-related stigma. In J. C. Hall, B.J. Hall & C. J. Cockerell (Eds.), HIV/AIDS in the Post-HAART Era:manifestations, treatment, and Epidemiology (pp. 790–806). Shelton, CT: PMPH-USA.

Sher, I., McGinn, L., Sirey, J.A. and Meyers, B. (2005) Effects of Caregivers’ Perceived Stigma and Causal Beliefs on Patients’ Adherence to Antidepressant Treatment. Pyschiatric Service 56(5).

Sirey, J.A., Bruce, M.L., Alexopoulos, G.S., Perlick, D.A., Raue, P., Friedman, S.J. and Meyers, B.S. (2001) Perceived Stigma as a Predictor of Treatment Discontinuation in Young and Older Outpatients with Depression. American Journal of Psychiatry 158(3)

Stutterheim, S. E., Pryor, J. B., Bos, A. E., Hoogendijk, R., Muris, P. and Schaalma, H. P. (2009). HIV-related stigma and psychological distress: The harmful effects of specific stigma manifestations in various social settings. AIDS, 23, 2353–2

Jessica Macdonald