Stigma and mental illness

This is a first blog written on my own account, so it’s offered with a degree of diffidence. At least the focus, on stigma, is familiar to me. The object is to reflect on ways in which the concept has salience for our grasp of mental illness. It is written in the wake of Ed Miliband’s re-assertion of our need to contest and overcome the prevailing stigma of mental illness. A review of the literature can be found in my chapter in The Sage Handbook of Mental Health and Illness, published in 2011. This blog is not a precis of this review, rather a few notes towards a credible sociological analysis of a damaging phenomenon.

(1)  Culturally lauded or acceptable behaviour, a staple of enduring sociality, is only possible if the breach of such norms is a realistic and publicly marked possibility. It was Durkheim who insisted that all social formations have discriminated between the normal and the abnormal, insiders and outsiders. There can be no ‘normal/acceptable’ in the absence of tangible examples of the ‘abnormal/unacceptable’. As Goffman said, there is a ‘self-other, normal-stigmatised unity’: stigmatised and non-stigmatised alike are products of the same norms. This is a good starting point for a sociologist.

(2)  The second point concerns ‘labelling’. If sociologists rarely now maintain that to attach a psychiatric label is to create mental illness (Scheff’s ‘aetiological hypothesis’), many still stress its negative outcomes (stigma, stereotyping etc). The so-called personal tragedy approach in medical sociology concentrates on these negative outcomes for individuals diagnosed with mental health problems. It was disability activists and theorists who directed attention back to the labellers rather than the labelled, in the process challenging the notion of the labelled as passive victims of disease. Their focus instead was on the role of labellers (doctors) as agents of social control or oppression. The problem was not the individuals with the disorder but the society that punished them.

(3)  Goffman again: stigma is anchored in the language of relationships. An attribute is not stigmatising per se. He treated in detail the often poignant day-to-day dealings of the ‘discredited’ (possessors of visible marks of unacceptable difference, challenged to manage impressions) and the ‘discreditable’ (possessors of invisible marks of unacceptable difference, challenged to manage information). Building on Goffman, I have defined stigma as indicative of an ontological deficit (of being imperfect). It implies an unwitting, non-culpable falling foul of cultural norms. Stigma denotes shame.

(4)  Stigma, I suggested, has three dimensions: (a) enacted stigma = discrimination by others on grounds of ‘being imperfect’; (b) felt stigma = internalised sense of shame + immobilising anticipation of enacted stigma; and (c) project stigma = strategies or tactics devised to avoid or combat enacted stigma without falling prey to felt stigma. There is evidence across many studies that felt stigma can be as damaging to people’s lives as enacted stigma; and there is evidence too that sociologists, if not disability theorists, have neglected the role of project stigma (or fighting back).

(5)  I have argued for an analytic distinction between stigma and deviance. Deviance refers to a moral deficit. While stigma denotes shame, deviance denotes blame. Moreover it can readily be seen that reference can also be made to enacted, felt and project deviance. Frequently, the effects of a complex dialectic between shame and blame can be discerned in the lives of people with mental illness. 

(6)  For sociologists, the nature and impact of infringements against norms of shame or blame must be set in a wider social context. Stigma and deviance can be inscribed on persons as well as embodied, but they are also ‘structured’ social relations. They tend in fact to follow society’s existing ‘fault lines’.

(7)  I have illustrated the relevance of structure by reference to New Labour’s US-inspired ‘welfare-to-work’ initiatives. Rooted in the premise that low employment rates amongst those with chronic physical or mental disorders contribute to the co-stigmas of poverty and social exclusion, these programmes were designed to ‘facilitate’ the transition from out-of-work benefit receipt to paid employment. Underlying the strategies on offer (education, training, placements, counselling, support, in-work benefits, employer incentives & improved accessibility) was an insistence on ‘demonstrable’ personal responsibility. I maintained that insofar as these strategies were ‘successful’, any gains in terms of reduced stigmatisation had to be set against costs in the currencies of economic exploitation (low paid work) and state oppression (compulsion and neglect). Stigmatisation is rarely the sole ingredient of disadvantage.

(7)  When deviance is also taken into account, a deeper picture emerges. Returning to the philosophy of ‘personal responsibility pushed by Blair, a political agenda can be seen in the transmutation of stigma into deviance,  shame into blame. If enough people are persuaded that ‘many’ of those with chronic physical and mental disorders can reasonably be held accountable/blamed for being ‘on benefits’, then cutting benefits becomes a realistic option.

Blair’s regime seems tame compared with the ConDem/Atos assault on people with long-term health problems today. But these notes add up to a hope that people interested in the stigma of mental illness will factor in the structural underpinnings of cultural norms and individual choice. If Foucault too readily discarded the sociology of domination, his genius was demonstrated in laying bare the seductive properties of power. Might it not be that enacted stigma and deviance can elide into government, and felt stigma and deviance into ‘governmentality’?