“Stigma” is a strong word: its social connotation is defined in the Shorter Oxford English Dictionary as “A mark or sign of disgrace or discredit, regarded as impressed on or carried by a person or thing.” Since its origins, the word, stigma, has been associated with harsh language that mirrors its harsh realities. Erving Goffman opened his classic text, Stigma: Notes on the Management of Spoiled Identity, with the following description: “The Greeks, who were apparently strong on visual aids, originated the term stigma to refer to bodily signs designed to expose something unusual and bad about the moral status of the signifier. The signs were cut or burnt into the body and advertised that the bearer was a slave, a criminal, or a traitor—a blemished person, ritually polluted, to be avoided, especially in public places.” Goffman elaborated, “By definition, of course, we believe the person with a stigma is not quite human.” Notoriously, mental illness can be stigmatizing. Is mental illness morally disgraceful? Does it render the sufferer not quite human? When we participate in stigmatizing persons with psychiatric disorders, we add insult to injury. The psychological curse of stigma is shame.
Disgrace and discredit are social phenomena with profound social consequences; as Goffman put it, stigma disqualifies the person from full social acceptance. Hence stigma results in discrimination and the associated social disadvantages, not the least of which can be denial of employment and decline of socioeconomic status. Psychological stress plays a central role in psychiatric disorders, and being stigmatized is a potentially compounding stressor. Those psychiatric patients who internalize the stigma—following the lead of society, disgracing themselves in their own mind—suffer further injury to their self-esteem. Their self-consciousness, social anxiety, and social avoidance enters into a vicious circle with social disadvantage, contributing to a pileup of stress and potentially exacerbating or perpetuating the psychiatric disorders for which they have been stigmatized. Especially problematic in compounding all these problems is the fact that stigma commonly interferes with seeking needed treatment.
In his memoir, Darkness Visible, author William Styron poignantly conveyed his experience of depression: “The mornings themselves were becoming bad now as I wandered about lethargic, following my synthetic sleep, but afternoons were still the worst, beginning at about three o’clock, when I’d feel the horror, like some poisonous fogbank, roll in upon my mind, forcing me into bed. There I would lie for as long as six hours, stuporous and virtually paralyzed, gazing at the ceiling and waiting for that moment of evening when, mysteriously, the crucifixion would ease up just enough to allow me to force down some food and then, like an automaton, seek an hour or two of sleep again. Why wasn’t I in the hospital?” (emphasis added). Answering this question, he explained that his psychiatrist counseled, “that I should try to avoid the hospital at all costs, owing to the stigma I might suffer.” He was hospitalized only after he became acutely suicidal, and he viewed the several-week inpatient stay as being essential to his recovery.
From shame to acceptance
Shame is an inducement to withdrawing from society, covering one’s face and hiding. In short, shame is alienating. Accordingly, as Goffman put it, “The central feature of the stigmatized individual’s situation in life can now be stated. It is a question of what is often, if vaguely, called ‘acceptance.’”. Overcoming shame entails making oneself known—being open and confiding—and meeting with acceptance, which restores a feeling of belonging in a community. Decades ago in his venerable text, The Theory and Practice of Group Psychotherapy, psychiatrist Irwin Yalom, MD, identified “universality” as one of the powerful healing aspects of treatment. In Yalom’s words, mutual self-disclosure in therapeutic groups results in a “welcome to the human race” experience—the antithesis of the “not quite human” mark of stigma that Goffman so eloquently challenged. Similarly, the feeling of being known and accepted is powerfully healing in therapeutic communities in psychiatric hospitals and residential treatment facilities.
When we embrace negative social stereotypes, we stigmatize. And we can do so unconsciously and unreflectively. Self-stigmatizing can occur in the same mindless fashion. Overcoming stigma calls for mentalizing, that is, attentiveness to mental states such as thoughts and feelings in oneself and others. Mentalizing entails being aware of the work of the mind. My colleague, Tom Ellis, has a poster in his office proclaiming “Don’t believe everything you think.” This mentalizing stance discourages us from confusing our mental states with the reality they represent. As Goffman perceptively stated, “The normal and the stigmatized are not persons but rather perspectives.” Thus, if we are to refrain from stigmatizing, the first step is mentalizing—being aware that we are stereotyping and being aware of the impact of that stereotyping process on our behavior and relationships. Contrary to stereotyping and stigmatizing, mentalizing encompasses mindfulness: keen attention to the present reality of another person, an open-minded curiosity relatively unencumbered by assumptions and prejudices. The path toward this admittedly utopian ideal, the best we can do, is putting our minds to it.