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’?

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4 thoughts on “Stigma and mental illness

  1. Graham (if I may),

    This is a great post, and I learned much reading it. I did have a question about #5, the analytic distinction between deviance and stigma.

    Because most of my work on stigma is in context of public health ethics, I typically borrow heavily from Link & Phelan’s formulation of stigma, especially since it ties in so nicely to power structures and social gradients which are what I focus on in my work anyway.

    As I understand their conception, they treat deviance as a criterion of stigma; it involves the normative assessment that constitutes the negative judgment (following the marking of an out-group as different on the basis of an identifiable characteristic).

    My question is, what is to be gained by distinguishing between stigma and deviance rather than simply treating deviance as a criterion for stigma? I am not sure I accept (or at least do not understand) a distinction between shame and blame that turns on the idea of a moral deficit. Wouldn’t some people feel shame — or believe others should — precisely because they perceive a moral deficit?

    I guess I have difficulty seeing how stigma, deviance, shame, and blame can be distinguished even sufficiently in analytic terms, and even if they can, I have difficulty seeing why it matters. That is, what do we lose under my reading of Link & Phelan’s formulation?

    • Daniel,

      My apologies for being so long replying. Being a novice I had to learn ‘how’. I agree that if one is on the receiving end of negative discrimination, whether this is shaming or blaming makes little difference and is unlikely to be of interest. In other words, it is not a distinction often salient for our everyday or first-order typifications of the worlds we live in.

      But I do think it worth preserving as a second-order typification of value to sociological analysis. The distinction is really around culpability. The possessor of a stigma is not judged culpable, the deviant is. This can be significant, as in the mid- to late 1980s when govs tried to get to grips with the emergence of HIV. Some people/patients were deemed ‘innocent’ (if infection followed a blood transfusion for example), others ‘guilty’ (if it resulted from a sharing of needles by injecting drug users), the differentiation between the two resting on the issue of putative culpability. In our neo-liberal era in which ‘personal responsibility’ has become a key ideological device, culpability assumes a special importance. Goffman said stigma had to do with ‘conformance’ not ‘compliance’. It is about what we ‘are’ not what we ‘do’. One of my arguments, easier to make if stigma and deviance are distinguished, is that govs are exerting greater central control/cutting benefits etc by recasting stigma as deviance, or by adding a charge of blame to that of shame.

      Many thanks for responding so constructively and helpfully. I shall think about it further.

      Graham.

      • Graham,

        Wonderful, thanks so much for the response. This helps, and FWIW, I entirely agree that the neoliberal emphasis on culpability and individual responsibility is crucial in understanding stigma.

        (Actually, I am investigating the historical rise and significance of the trope, but that’s another matter entirely).

        Thanks much, and love the blog!

  2. Pingback: Shame | Abetternhs's Blog

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