By Prof Dr Sohail Ansari “Believers! do not nullify your charitable deed by posing as munificent or by painfully embarrassing others, as do those who expend their wealth just to be seen of men, with no faith in God and the Last Day. 2:

The absurdity of a question

· The excellence of answer is the excellence of question, and the impossibility of answer is the absurdity of question. ‘What will happen if man defeats God?’ answer is not possible as it is not possible.

Social stigma refers to extreme disapproval of (or discontent with) a person or group on socially characteristic grounds that are perceived, and serve to distinguish them, from other members of a society. Stigma may then be affixed to such a person, by the greater society, who differs from their cultural norms.

Social stigma can result from the perception and judgment of mental disorder, physical disabilities, diseases such as leprosy,^[1] illegitimacy, sexual orientation, gender identity,^[2] parenthood, sexuality, beliefs, values, education, nationality, ethnicity, power, prestige, wealth, occupation, class, religion, beauty, relationship, intellect, sexual assault or criminality. Attributes associated with social stigma often vary depending on the geopolitical and corresponding sociopolitical contexts employed by society, in different parts of the world.

According to Erving Goffman there are three forms of social stigma:^[3]

1. Overt or external deformations, such as scars, physical manifestations of anorexia nervosa, leprosy (leprosy stigma), or of a physical disability or social disability, such as obesity.

2. Deviations in personal traits, including dropping out of school, working a low wage job, single parenthood, bankruptcy, unemployment, welfare dependency, adultery, mental disorder, teenage pregnancy, drug addiction, alcoholism, and criminal background are stigmatized in this way.

3. "Tribal stigmas" are traits (imagined or real) of an ethnic group, nationality, or religion that is deemed to be a deviation from the prevailing normative ethnicity, nationality, or religion.

Description[edit]

Stigma is a Greek word that in its origins referred to a type of marking or tattoo 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.^[4]

Social stigmas can occur in many different forms. The most common deal with culture, obesity, gender, race, illness and disease. Many people who have been stigmatized, feel as though they are transforming from a whole person to a tainted one. They feel different and devalued by others. This can happen in the workplace, educational settings, health care, the criminal justice system, and even in their own family. For example, the parents of overweight women are less likely to pay for their daughters' college education than are the parents of average-weight women.^[5]

Stigma may also be described as a label that associates a person to a set of unwanted characteristics that form a stereotype. It is also affixed.^[6] Once people identify and label your differences others will assume that is just how things are and the person will remain stigmatized until the stigmatizing attribute is undetected. A considerable amount of generalization is required to create groups, meaning that you put someone in a general group regardless of how well they actually fit into that group. However, the attributes that society selects differ according to time and place. What is considered out of place in one society could be the norm in another. When society categorizes individuals into certain groups the labeled person is subjected to status loss and discrimination.^[6]Society will start to form expectations about those groups once the cultural stereotype is secured.

Stigma may affect the behavior of those who are stigmatized. Those who are stereotyped often start to act in ways that their stigmatizers expect of them. It not only changes their behavior, but it also shapes their emotions and beliefs.^[5] Members of stigmatized social groups often face prejudice that causes depression (i.e. deprejudice).^[7]These stigmas put a person's social identity in threatening situations, like low self-esteem. Because of this, identity theories have become highly researched. Identity threat theories can go hand-in-hand with labeling theory.

Members of stigmatized groups start to become aware that they aren't being treated the same way and know they are probably being discriminated against. Studies have shown that "by 10 years of age, most children are aware of cultural stereotypes of different groups in society, and children who are members of stigmatized groups are aware of cultural types at an even younger age."^[5]

Main theories and contributions[edit]

Émile Durkheim[edit]

French sociologist Émile Durkheim was the first to explore stigma as a social phenomenon in 1895. He wrote:

Imagine a society of saints, a perfect cloister of exemplary individuals. Crimes or deviance, properly so-called, will there be unknown; but faults, which appear venial to the layman, will there create the same scandal that the ordinary offense does in ordinary consciousnesses. If then, this society has the power to judge and punish, it will define these acts as criminal (or deviant) and will treat them as such.^[8]

Erving Goffman[edit]

Erving Goffman was one of the most influential sociologists of the twentieth century. He defined stigma as:^[3]

The phenomenon whereby an individual with an attribute which is deeply discredited by his/her society is rejected as a result of the attribute. Stigma is a process by which the reaction of others spoils normal identity.

Gerhard Falk[edit]

German born sociologist and historian Gerhard Falk wrote:^[9]

All societies will always stigmatize some conditions and some behaviors because doing so provides for group solidarity by delineating "outsiders" from "insiders".

Falk^[10] describes stigma based on two categories, existential stigma and achieved stigma. Falk defines existential stigma "as stigma deriving from a condition which the target of the stigma either did not cause or over which he has little control." He defines Achieved Stigma as "stigma that is earned because of conduct and/or because they contributed heavily to attaining the stigma in question."^[9]

Falk concludes that "we and all societies will always stigmatize some condition and some behavior because doing so provides for group solidarity by delineating 'outsiders' from 'insiders'".^[9] Stigmatization, at its essence is a challenge to one's humanity- for both the stigmatized person and the stigmatizer. The majority of stigma researchers have found the process of stigmatization has a long history and is cross-culturally ubiquitous.^[11]

Goffman's theory[edit]

In Erving Goffman's theory of social stigma, a stigma is an attribute, behavior, or reputation which is socially discrediting in a particular way: it causes an individual to be mentally classified by others in an undesirable, rejected stereotype rather than in an accepted, normal one. Goffman, a noted sociologist, defined stigma as a special kind of gap between virtual social identity and actual social identity:

Society establishes the means of categorizing persons and the complement of attributes felt to be ordinary and natural for members of each of these categories. [...] When a stranger comes into our presence, then, first appearances are likely to enable us to anticipate his category and attributes, his "social identity" [...] We lean on these anticipations that we have, transforming them into normative expectations, into righteously presented demands. [...] It is [when an active question arises as to whether these demands will be filled] that we are likely to realize that all along we had been making certain assumptions as to what the individual before us ought to be. [These assumed demands and the character we impute to the individual will be called] virtual social identity. The category and attributes he could in fact be proved to possess will be called his actual social identity. (Goffman 1963:2).

While a stranger is present before us, evidence can arise of his possessing an attribute that makes him different from others in the category of persons available for him to be, and of a less desirable kind--in the extreme, a person who is quite thoroughly bad, or dangerous, or weak. He is thus reduced in our minds from a whole and usual person to a tainted, discounted one. Such an attribute is a stigma, especially when its discrediting effect is very extensive [...] It constitutes a special discrepancy between virtual and actual social identity. Note that there are other types of [such] discrepancy [...] for example the kind that causes us to reclassify an individual from one socially anticipated category to a different but equally well-anticipated one, and the kind that causes us to alter our estimation of the individual upward. (Goffman 1963:3).

The stigmatized, the normal, and the wise[edit]

Goffman divides the individual's relation to a stigma into three categories:

1. the stigmatized are those who bear the stigma;

2. the normals are those who do not bear the stigma; and

3. the wise are those among the normals who are accepted by the stigmatized as "wise" to their condition (borrowing the term from the homosexual community).

The wise normals are not merely those who are in some sense accepting of the stigma; they are, rather, "those whose special situation has made them intimately privy to the secret life of the stigmatized individual and sympathetic with it, and who find themselves accorded a measure of acceptance, a measure of courtesy membership in the clan." That is, they are accepted by the stigmatized as "honorary members" of the stigmatized group. "Wise persons are the marginal men before whom the individual with a fault need feel no shame nor exert self-control, knowing that in spite of his failing he will be seen as an ordinary other." Goffman notes that the wise may in certain social situations also bear the stigma with respect to other normals: that is, they may also be stigmatized for being wise. An example is a parent of a homosexual; another is a white woman who is seen socializing with a black man. (Limiting ourselves, of course, to social milieus in which homosexuals and blacks are stigmatized).

Until recently, this typology has been used without being empirically tested. A recent study^[12] showed empirical support for the existence of the own, the wise, and normals as separate groups; but, the wise appeared in two forms: active wise and passive wise. Active wise encouraged challenging stigmatization and educating stigmatizers, but passive wise did not.

Ethical considerations[edit]

Goffman emphasizes that the stigma relationship is one between an individual and a social setting with a given set of expectations; thus, everyone at different times will play both roles of stigmatized and stigmatizer (or, as he puts it, "normal"). Goffman gives the example that "some jobs in America cause holders without the expected college education to conceal this fact; other jobs, however, can lead to the few of their holders who have a higher education to keep this a secret, lest they be marked as failures and outsiders. Similarly, a middle class boy may feel no compunction in being seen going to the library; a professional criminal, however, writes [about keeping his library visits secret]." He also gives the example of blacks being stigmatized among whites, and whites being stigmatized among blacks.

Individuals actively cope with stigma in ways that vary across stigmatized groups, across individuals within stigmatized groups, and within individuals across time and situations.^[13]

The stigmatized[edit]

The stigmatized are ostracized, devalued, rejected, scorned and shunned. They experience discrimination and prejudice in the realms of employment and housing.^[14] Perceived prejudice and discrimination is also associated with negative physical and mental health outcomes.^[15] Those who perceive themselves to be members of a stigmatized group, whether it is obvious to those around them or not, often experience psychological distress and many view themselves contemptuously.^[11]

Although the experience of being stigmatized may take a toll on self-esteem, academic achievement, and other outcomes, many people with stigmatized attributes have high self-esteem, perform at high levels, are happy and appear to be quite resilient to their negative experiences.^[11]

There are also "positive stigma": you may indeed be too rich, or too smart. This is noted by Goffman (1963:141) in his discussion of leaders, who are subsequently given license to deviate from some behavioral norms, because they have contributed far above the expectations of the group.

The stigmatizer[edit]

From the perspective of the stigmatizer, stigmatization involves dehumanization, threat, aversion^{[clarification
needed]}and sometimes the depersonalization of others into stereotypic caricatures. Stigmatizing others can serve several functions for an individual, including self-esteem enhancement, control enhancement, and anxiety buffering, through downward-comparison—comparing oneself to less fortunate others can increase one's own subjective sense of well-being and therefore boost one's self-esteem.^[11]

21st century social psychologists consider stigmatizing and stereotyping to be a normal consequence of people's cognitive abilities and limitations, and of the social information and experiences to which they are exposed.^[11]

Current views of stigma, from the perspectives of both the stigmatizer and the stigmatized person, consider the process of stigma to be highly situationally specific, dynamic, complex and nonpathological.^[11]

Link and Phelan stigmatization model[edit]

Bruce Link and Jo Phelan propose that stigma exists when four specific components converge:^[16]

1. Individuals differentiate and label human variations.

2. Prevailing cultural beliefs tie those labeled to adverse attributes.

3. Labeled individuals are placed in distinguished groups that serve to establish a sense of disconnection between "us" and "them".

4. Labeled individuals experience "status loss and discrimination" that leads to unequal circumstances.

In this model stigmatization is also contingent on "access to social, economic, and political power that allows the identification of differences, construction of stereotypes, the separation of labeled persons into distinct groups, and the full execution of disapproval, rejection, exclusion, and discrimination." Subsequently, in this model the term stigma is applied when labeling, stereotyping, disconnection, status loss, and discrimination all exist within a power situation that facilitates stigma to occur.

Differentiation and labeling[edit]

Identifying which human differences are salient, and therefore worthy of labeling, is a social process. There are two primary factors to examine when considering the extent to which this process is a social one. The first issue is that significant oversimplification is needed to create groups. The broad groups of black and white, homosexual and heterosexual, the sane and the mentally ill; and young and old are all examples of this. Secondly, the differences that are socially judged to be relevant differ vastly according to time and place. An example of this is the emphasis that was put on the size of forehead and faces of individuals in the late 19th century—which was believed to be a measure of a person's criminal nature.

Linking to stereotypes[edit]

The second component of this model centers on the linking of labeled differences with stereotypes. Goffman's 1963 work made this aspect of stigma prominent and it has remained so ever since. This process of applying certain stereotypes to differentiated groups of individuals has attracted a large amount of attention and research in recent decades.

Us and them[edit]

Thirdly, linking negative attributes to groups facilitates separation into "us" and "them". Seeing the labeled group as fundamentally different causes stereotyping with little hesitation. "Us" and "them" implies that the labeled group is slightly less human in nature, and at the extreme not human at all. At this extreme, the most horrific events occur.

Disadvantage[edit]

The fourth component of stigmatization in this model includes "status loss and discrimination". Many definitions of stigma do not include this aspect, however these authors believe that this loss occurs inherently as individuals are "labeled, set apart, and linked to undesirable characteristics." The members of the labeled groups are subsequently disadvantaged in the most common group of life chances including income, education, mental well-being, housing status, health, and medical treatment. Thus, stigmatization by the majorities, the powerful, or the "superior" leads to the Othering of the minorities, the powerless, and the "inferior". Where by the stigmatized individuals become disadvantaged due to the ideology created by "the self," which is the opposing force to "the Other." As a result, the others become socially excluded and those in power reason the exclusion based on the original characteristics that led to the stigma.^[17]

Necessity of power[edit]

The authors also emphasize the role of power (social, economic, and political power) in stigmatization. While the use of power is clear in some situations, in others it can become masked as the power differences are less stark. An extreme example of a situation in which the power role was explicitly clear was the treatment of Jewish people by the Nazis. On the other hand, an example of a situation in which individuals of a stigmatized group have "stigma-related processes"^{[clarification
needed]} occurring would be the inmates of a prison. It is imaginable that each of the steps described above would occur regarding the inmates' thoughts about the guards. However, this situation cannot involve true stigmatization, according to this model, because the prisoners do not have the economic, political, or social power to act on these thoughts with any serious discriminatory consequences.

'Stigma allure' and authenticity[edit]

Sociologist Matthew W. Hughey explains that prior research on stigma has emphasized individual and group attempts to reduce stigma by 'passing as normal', by shunning the stigmatized, or through selective disclosure of stigmatized attributes. Yet, some actors may embrace particular markings of stigma (e.g.: social markings like dishonor or select physical dysfunctions and abnormalities) as signs of moral commitment and/or cultural and political authenticity. Hence, Hughey argues that some actors do not simply desire to 'pass into normal' but may actively pursue a stigmatized identity formation process in order to experience themselves as causal agents in their social environment. Hughey calls this phenomenon 'stigma allure'.^[18]

The Six Dimensions of Stigma[edit]

While often incorrectly attributed to Goffman the "Six Dimensions of Stigma" were not his invention. They were developed to augment Goffman's two levels – the discredited and the discreditable. Goffman considered individuals whose stigmatizing attributes are not immediately evident. In that case, the individual can encounter two distinct social atmospheres. In the first, he is discreditable—his stigma has yet to be revealed, but may be revealed either intentionally by him (in which case he will have some control over how) or by some factor he cannot control. Of course, it also might be successfully concealed; Goffman called this passing. In this situation, the analysis of stigma is concerned only with the behaviors adopted by the stigmatized individual to manage his identity: the concealing and revealing of information. In the second atmosphere, he is discredited—his stigma has been revealed and thus it affects not only his behavior but the behavior of others. Jones et al. (1984) added the "six dimensions" and correlate them to Goffman's two types of stigma, discredited and discreditable.

There are six dimensions that match these two types of stigma:^[19]

1. Concealable – extent to which others can see the stigma

2. Course of the mark – whether the stigma's prominence increases, decreases, or remains consistent over time

3. Disruptiveness – the degree to which the stigma and/or others' reaction to it impede social interactions

4. Aesthetics – the subset of others' reactions to the stigma comprising reactions that are positive/approving or negative/disapproving but represent estimations of qualities other than the stigmatized person's inherent worth or dignity

5. Origin – whether others think the stigma is present at birth, accidental, or deliberate

6. Peril – the danger that others perceive (whether accurately or inaccurately) the stigma to pose to them

Types[edit]

In Unraveling the contexts of stigma, authors Campbell and Deacon describe Goffman's universal and historical forms of Stigma as the following.

· Overt or external deformities - such as leprosy, clubfoot, cleft lip or palate and muscular dystrophy.

· Known deviations in personal traits - being perceived rightly or wrongly, as weak willed, domineering or having unnatural passions, treacherous or rigid beliefs, and being dishonest, e.g., mental disorders, imprisonment, addiction, homosexuality, unemployment, suicidal attempts and radical political behavior.

· Tribal stigma - affiliation with a specific nationality, religion, or race that constitute a deviation from the normative, i.e. being African American, or being of Arab descent in the United States after the 9/11 attacks.^[20]

Deviance[edit]

Stigma occurs when an individual is identified as deviant, linked with negative stereotypes that engender prejudiced attitudes, which are acted upon in discriminatory behavior. Goffman illuminated how stigmatized people manage their "Spoiled identity" (meaning the stigma disqualifies the stigmatized individual from full social acceptance) before audiences of normals. He focused on stigma, not as a fixed or inherent attribute of a person, but rather as the experience and meaning of difference.^[21]

Gerhard Falk expounds upon Goffman's work by redefining deviant as "others who deviate from the expectations of a group" and by categorizing deviance into two types:

· Societal deviance refers to a condition widely perceived, in advance and in general, as being deviant and hence stigma and stigmatized. "Homosexuality is therefore an example of societal deviance because there is such a high degree of consensus to the effect that homosexuality is different, and a violation of norms or social expectation".^[9]

· Situational deviance refers to a deviant act that is labeled as deviant in a specific situation, and may not be labeled deviant by society. Similarly, a socially deviant action might not be considered deviant in specific situations. "A robber or other street criminal is an excellent example. It is the crime which leads to the stigma and stigmatization of the person so affected."

The physically disabled, mentally ill, homosexuals, and a host of others who are labeled deviant because they deviate from the expectations of a group, are subject to stigmatization- the social rejection of numerous individuals, and often entire groups of people who have been labeled deviant.

Stigma communication[edit]

Communication is involved in creating, maintaining, and diffusing stigmas, and enacting stigmatization.^[22] The model of stigma communication explains how and why particular content choices (marks, labels, peril, and responsibility) can create stigmas and encourage their diffusion.^[23] A recent experiment using health alerts tested the model of stigma communication, finding that content choices indeed predicted stigma beliefs, intentions to further diffuse these messages, and agreement with regulating infected persons' behaviors.^[22][24]

Challenging[edit]

Stigma, though powerful and enduring, is not inevitable, and can be challenged. There are two important aspects to challenging stigma: challenging the stigmatisation on the part of stigmatizers, and challenging the internalized stigma of the stigmatized. To challenge stigmatization, Campbell et al. 2005^[25] summarise three main approaches.

1. There are efforts to educate individuals about the non-stigmatising facts and why they should not stigmatise.

2. There are efforts to legislate against discrimination.

3. There are efforts to mobilize the participation of community members in anti-stigma efforts, to maximize the likelihood that the anti-stigma messages have relevance and effectiveness, according to local contexts.

In relation to challenging the internalized stigma of the stigmatized, Paulo Freire's theory of critical consciousness is particularly suitable. Cornish provides an example of how sex workers in Sonagachi, a red light district in India, have effectively challenged internalized stigma by establishing that they are respectable women, who admirably take care of their families, and who deserve rights like any other worker.^[26] This study argues that it is not only the force of rational argument that makes the challenge to the stigma successful, but concrete evidence that sex workers can achieve valued aims, and are respected by others.

Current research[edit]

Research undertaken to determine effects of social stigma primarily focuses on disease-associated stigmas. Disabilities, psychiatric disorders, and sexually transmitted diseases are among the diseases currently scrutinized by researchers. In studies involving such diseases, both positive and negative effects of social stigma have been discovered.^{[clarification
needed]}

Research on self-esteem[edit]

Main article: Self-esteem

Members of stigmatized groups may have lower self-esteem than those of nonstigmatized groups. A test could not be taken on the overall self-esteem of different races. Researchers would have to take into account whether these people are optimistic or pessimistic, whether they are male or female and what kind of place they grew up in. Over the last two decades, many studies have reported that African Americans show higher global self-esteem than whites even though, as a group, African Americans tend to receive poorer outcomes in many areas of life and experience significant discrimination and stigma.

Correlations between self-esteem and achievement tests:

		8th grade	10th grade
African American	Male	.235	.192
African American	Female	.152	.159
European American	Male	.140	.165
European American	Female	.163	.166

Correlations between self-esteem and GPA^{[clarification
needed]}:

		8th grade	10th grade
African American	Male	.206	.081
African American	Female	.260	.207
European American	Male	.227	.241
European American	Female	.279	.269

Average weight women have higher self-esteem than overweight women. Overweight women who are older have lower levels of collective self-esteem on an implicit measure but have equivalent levels of personal self-esteem on both implicit and explicit measures.^{[clarification
needed]}

The US Department of Health, Education and Welfare determined that including the 24% of women who are actually obese, 60% of adolescent women believe they are overweight. Recent studies have shown that women who are "unattractive" or obese do not believe they will make a good impression on the men they come into contact with, which makes the men feel the women are uncomfortable and uninterested in them. The women of average weight felt better about the impression they would make on the men^{[clarification
needed]}, and in return the men felt the women were interested in them and enjoyed their company.

This test showed how obese or overweight women have low self-esteem. Obese women and overweight women feel uncomfortable, and aren't very social, which makes the people they come into contact with uninterested and uncomfortable. The more overweight the woman is, the lower her self-esteem tends to be.

People with mental disorders[edit]

Further information: Mental disorder § Stigma

Empirical research on stigma associated with mental disorders, pointed to a surprising attitude of the general public. Those who were told that mental disorders had a genetic basis were more prone to increase their social distance from the mentally ill, and also to assume that the ill were dangerous individuals, in contrast with those members of the general public who were told that the illnesses could be explained by social and environment factors. Furthermore, those informed of the genetic basis were also more likely to stigmatize the entire family of the ill.^[27] Although the specific social categories that become stigmatized can vary over time and place, the three basic forms of stigma (physical deformity, poor personal traits, and tribal outgroup status) are found in most cultures and eras, leading some researchers to hypothesize that the tendency to stigmatize may have evolutionary roots.^[28][29]

Currently, several researchers believe that mental disorders are caused by a chemical imbalance in the brain. Therefore, this biological rationale suggests that individuals struggling with a mental illness do not have control over the origin of the disorder. Much like cancer or another type of physical disorder, persons suffering from mental disorders should be supported and encouraged to seek help. Unlike physical disabilities, there is a negative social stigma surrounding mental illness, with those suffering being perceived to have control of their disabilities and being responsible for causing them. "Furthermore, research respondents are less likely to pity persons with mental illness, instead reacting to psychiatric disability with anger and believing that help is not deserved." ^[30] Although there are effective mental health interventions available across the globe, many persons with mental illnesses do not seek out the help that they need. Only 59.6% of individuals with a mental illness, including conditions such as depression, anxiety, schizophrenia, and bipolar disorder, reported receiving treatment in 2011.^[31] Reducing the negative stigma surrounding mental disorders may increase the probability of afflicted individuals seeking professional help from a psychiatrist or a non-psychiatric physician.

In the music industry, specifically in the genre of hip-hop or rap, those who speak out on mental illness are heavily criticized. However, according to a The Huffington Post article, there's a significant increase in rappers who are breaking their silence on depression and anxiety.^[32]

Addiction and Substance Use Disorders[edit]

Throughout history, addiction has largely been seen as a moral failing or character flaw, as opposed to an issue of public health.^[33][34][35] Substance use has been found to be more stigmatized than smoking, obesity, and mental illness.^{[33][36][37][38]} Research has shown stigma to be a barrier to treatment-seeking behaviors among individuals with addiction, creating a "treatment gap".^[39][40][41] Research shows that the words used to talk about addiction can contribute to stigmatization, and that the commonly used terms of "abuse" & "abuser" actually increase stigma.^{[42][43][44][45]} Substance Use related addictions are found to be more stigmatized than behavioral addictions (i.e. gambling, sex, etc.).^[46] Stigma is reduced when Substance Use Disorders are portrayed as treatable conditions.^[47][48] Acceptance and Commitment Therapy has been used effectively to help people to reduce shame associated with cultural stigma around substance use treatment.^[49][50][51]

Mental illness, Taiwan[edit]

In Taiwan, strengthening the psychiatric rehabilitation system has been one of the primary goals of the Department of Health since 1985. Unfortunately, this endeavor has not been successful and it is believed that one of the barriers is social stigma towards the mentally ill.^[52] Accordingly, a study was conducted to explore the attitudes of the general population towards patients with mental disorders. A survey method was utilized on 1,203 subjects nationally. The results revealed that the general population held high levels of benevolence, tolerance on rehabilitation in the community, and nonsocial restrictiveness.^[52] Essentially, benevolent attitudes were favoring the acceptance of rehabilitation in the community. It could then be inferred that the belief (held by the residents of Taiwan) in treating the mentally ill with high regard, somewhat eliminated the stigma.^[52]

Epilepsy, Hong Kong[edit]

Epilepsy, a common neurological disorder characterised by recurring seizures, is associated with various social stigmas. Chung-yan Gardian Fong and Anchor Hung conducted a study in Hong Kong which documented public attitudes towards individuals with epilepsy. Of the 1,128 subjects interviewed, only 72.5% of them considered epilepsy to be acceptable;^{[clarification
needed]} 11.2% would not let their children play with others with epilepsy; 32.2% would not allow their children to marry persons with epilepsy; additionally, employers (22.5% of them) would terminate an employment contract after an epileptic seizure occurred in an employee with unreported epilepsy.^[53]Suggestions were made that more effort be made to improve public awareness of, attitude toward, and understanding of epilepsy through school education and epilepsy-related organizations.^[53]

In the media[edit]

In the early 21st century, technology has a large impact on the lives of people in multiple countries and has become a social norm. Many people own a television, computer, and a smart phone. The media can be helpful with keeping people up to date on news and world issues and it is very influential on people. Because it is so influential sometimes the portrayal of minority groups affects attitudes of other groups toward them. Much media coverage has to do with other parts of the world. A lot of this coverage has to do with war and conflict, which people may relate to any person belonging from that country. There is a tendency to focus more in the positive behaviour of one's own group and the negative behaviours of other groups. This promotes negative thoughts of people belonging to those other groups, reinforcing stereotypical beliefs.^[54]

"Viewers seem to react to violence with emotions such as anger and contempt. They are concerned for the integrity of the social order and show disapproval of others. Emotions such as sadness and fear are shown much more rarely." (Unz, Schwab & Winterhoff-Spurk, 2008, p. 141)^[55]

In a study testing the effects of stereotypical advertisements on students, 75 high school students viewed magazine advertisements with stereotypical female images such as a woman working on a holiday dinner, while 50 others viewed non stereotypical images such as a woman working in a law office. These groups then responded to statements about women in a "neutral" photograph. In this photo a woman was shown in a casual outfit not doing any obvious task. The students that saw the stereotypical images tended to answer the questionnaires with more stereotypical responses in 6 of the 12 questionnaire statements. This suggests that even brief exposure to stereotypical ads reinforces stereotypes.(Lafky, Duffy, Steinmaus & Berkowitz, 1996)^[56]

Effects of education, culture[edit]

The aforementioned stigmas (associated with their respective diseases) propose effects that these stereotypes have on individuals. Whether effects be negative or positive in nature, 'labeling' people causes a significant change in individual perception (of persons with disease). Perhaps a mutual understanding of stigma, achieved through education, could eliminate social stigma entirely.

Laurence J. Coleman first adapted Erving Goffman's (1963) social stigma theory to gifted children, providing a rationale for why children may hide their abilities and present alternate identities to their peers.^[57][58][59] The stigma of giftedness theory was further elaborated by Laurence J. Coleman and Tracy L. Cross in their book entitled, Being Gifted In School, which is a widely cited reference in the field of gifted education.^[60] In the chapter on Coping with Giftedness, the authors expanded on the theory first presented in an 1988 article.^[61] According to Google Scholar, this article has been cited at least 110 times in the academic literature.^[62]

Coleman and Cross were the first to identify intellectual giftedness as a stigmatizing condition and they created a model based on Goffman's (1963) work, research with gifted students,^[59] and a book that was written and edited by 20 teenage, gifted individuals.^[63] Being gifted sets students apart from their peers and this difference interferes with full social acceptance. Varying expectations that exist in the different social contexts which children must navigate, and the value judgments that may be assigned to the child result in the child's use of social coping strategies to manage his or her identity. Unlike other stigmatizing conditions, giftedness is a unique because it can lead to praise or ridicule depending on the audience and circumstances.

Gifted children learn when it is safe to display their giftedness and when they should hide it to better fit in with a group. These observations led to the development of the Information Management Model that describes the process by which children decide to employ coping strategies to manage their identities. In situations where the child feels different, she or he may decide to manage the information that others know about him or her. Coping strategies include: disidentification with giftedness, attempting to maintain a low visibility, or creating a high-visibility identity (playing a stereotypical role associated with giftedness). These ranges of strategies are called the Continuum of Visibility.

Stigmatising attitude of narcissists to psychiatric illness[edit]

Arikan found that a stigmatising attitude to psychiatric patients is associated with narcissistic personality traits.^[64]

Abortion[edit]

While abortion medicine is very common in western society, women rarely disclose their use of such services, and providers are also subject to stigma.^[65][66]

Managing Stigma Effectively: What Social Psychology and Social Neuroscience Can Teach Us

James L. Griffith¹ and Brandon A. Kohrt²

Author information ► Copyright and License information ►

The publisher's final edited version of this article is available at Acad Psychiatry

Abstract

Keywords:

The Greeks, who were apparently strong on visual aids, originated the term stigma to refer to bodily sins 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.

“From Stigma by Erving Goffman ([1], p. 1)”

People diagnosed with mental illnesses are too often viewed as incompetent, irresponsible, unpredictable, and dangerous [2]. Psychiatrists are often viewed negatively by the public and medical colleagues as odd, ineffectual, agents of repression, abusive, or suffering from mental illnesses [3]. A 2009 Task Force of the World Psychiatric Association (WPA) found stigma against psychiatry and psychiatrists to exist in every society studied [3]. Professional psychiatric organizations repeatedly attempt campaigns against stigma as a centerpiece of health policy and advocacy. After examining 7296 publications worldwide, however, the WPA Task Force found a scarcity of research on interventions that effectively combat stigma, and no studies at all on interventions specifically targeting stigmatization and discrimination of psychiatrists [3]. Further, public campaigns and interventions to educate the public about the neurobiological bases of mental illnesses have limited benefits and may worsen stigmatization of person with mental illness [4–6]. The term “stigma” itself has come under scrutiny as too all-inclusive for a broad range of negative experiences associated with mental illness, thus limiting elucidation of specific mechanisms and effective interventions.

There are reasons for optimism, however. Recent decades of social psychology research have identified fundamental and distinct social processes that produce stereotyping, stigmatization, prejudice, and discrimination [2]. Interventions that facilitate face-to-face interactions between health workers and persons in recovery from mental illnesses have shown promise for reducing stigma [5]. Processes by which these social exposure models work is supported by social neuroscience research, which has elucidated neural circuitry of social cognition that transforms detection of a mark of stigma into specific aversive emotions and discriminatory behaviors [7]. This emerging understanding of social cognition at behavioral and neural circuitry levels has opened new avenues for defining and combating stigma against psychiatry and mental illnesses. We suggest that

Social neuroscience research can display step-wise, sequential processing of social information within brain circuitry and signaling pathways;
Stigma assessment based upon social psychology and social neuroscience can identify types of stigma with strategies best fitted for countering that type;
Social psychology research has begun empirically validating effective interventions for neutralizing stigma and prejudice. However, these evidence-based interventions have not yet been broadly disseminated within psychiatric training and clinical practices. A clinical model for stigma management based upon social psychology and social neuroscience research can help remedy this shortfall if taught during psychiatry residencies.

The George Washington University (GWU) psychiatry residency has developed a curriculum for training psychiatry residents to assess, formulate, and implement interventions to attenuate stigma. This is in keeping with the Accreditation Council on Graduate Medical Education (ACGME) and American Board of Psychiatry and Neurology (ABPN) Milestone Project, which identifies integration of knowledge of neurobiology into advocacy for psychiatric patient care and stigma reduction (Milestone 5.4/D) as a high-tier competency [8]. The GWU curriculum is informed by social psychology and social neuroscience research [9–11]. In this paper, we present the conceptual background for understanding stigma from a social psychology and social neuroscience perspective. Then, we summarize educational modules with associated case illustrations for teaching residents.

This innovative curriculum addresses three gaps in academic psychiatry: the lack of interventions for stigma reduction in psychiatric care; the lack of training techniques on stigma reduction for trainees; and the lack of models for stigma reduction that incorporate neuroscience in accord with ACGME/ABPN Milestones [8].

Stigma—An Affliction of Normal People and Normal Brains

Stigma is “the situation of the individual who is disqualified from full social acceptance” ([1], preface) due to “the dynamics of shameful differentness” ([1], p. 140). Stigma is a social construction that involves two fundamental components: the recognition of difference based on some distinguishing characteristic—a “mark,” and a consequent devaluation of that person [1, 12]. Stigma can arise from membership in a group, such as “the mentally ill” or “psychiatrists,” who are devalued in particular social contexts [13]. Stigmatized individuals are regarded as flawed, compromised, and somehow less than fully human, identifiable by the presence of their mark. Stigma can rob a person with a mental illness of much that makes life worth living.

Goffman’s original ethnographic descriptions of how stigma processes occur have been updated through understandings from evolutionary psychology about why stigmatization occurs. Evolutionary psychology suggests that stigma is a byproduct of normal group behavior [14]. Hominid evolution was associated with increasing capacities for organizing tightly cohesive, organized groups. These capacities manifest as leadership and followership, hierarchy, roles and responsibilities, boundaries, and reciprocal altruism within groups. The capacity to detect group members who were deemed too different or who risked impeding the group’s functioning became the human capacity to stigmatize.

From an evolutionary perspective, stigma is cognitively efficient: stigma results from cognitive heuristics and biases that make reflective thought unnecessary for rapid social judgments [15]. Functional brain imaging has clarified how these evolutionary processes of social cognition derive from dual systems: one for rapid, categorical, group member-to-group member relatedness and another for slower, individualized, person-to-person relatedness. Categorical social cognition functions as a threat detection and management system that ensures security of the group. Categorical social cognition relies upon sociobiological systems that act as sensors, conducting surveillance over social space. These include sociobiological systems for social hierarchy, peer affiliation (ingroup social bonds), social exchange (in-group reciprocal altruism), and kin recognition (distinguishing in-group from out-group members) ([16], pp. 13–55). Each system appears to have distinct circuitry elements [17].

Types of stigma reflect different survival concerns for the reference group and are reflected in different methods for social surveillance. These different methods require specific counter-tactics to disrupt their operations. Stigma types particularly relevant for persons with mental illnesses include the following:

1. Peril stigma triggers perceptions of potential danger, such as a person with a mental illness who shows odd, impulsive, or unpredictable behaviors;

2. Moral stigma is stigma in which a person is perceived as a threat for challenging the group’s beliefs and values. Symptoms of mental illness, such as a patient’s negative symptoms of psychosis, behavioral avoidance of anxiety disorders, or apathy of depression, may trigger moral stigma when interpreted as laziness, unwillingness to accept personal responsibility for one’s life, or lack of predictable conformity to social rules of engagement.

3. Disruption stigma occurs when a person’s behaviors or symptoms are experienced as interfering with functioning of the family or work group. Interaction with persons living with physical disabilities may invoke disruption stigma because of concern that professional and social obligations will be threatened by tending to that person’s needs. Within healthcare systems, clinicians engage in disruption stigma when psychiatric patients are not given equal diagnostic vigilance or when they are “dumped” onto other services.

4. Empathy fatigue represents a form of stigma when family members, friends, and co-workers feel too distressed to engage in close proximity with persons in suffering, i.e., a feeling that it is “too much emotional work.” The result is avoidance or high levels of social distance. Mental illnesses associated with feelings of severe depression, anxiety, and chronic pain may evoke empathy fatigue.

5. Courtesy stigma is stigma by association that results in loss of social status with physical proximity to a stigmatized person, as if acquiring “courtesy membership” in the stigmatized group [1]. Family members or mental health professionals are vulnerable to courtesy stigma by virtue of association with persons with mental illness.

The most difficult of all stigmatizing processes to counter is perhaps internalized stigma. Internalized stigma results when stigma of whatever specific type becomes a lens for self-perception that is judgmental, contemptuous, and dismissive [4]. Patients feel disgust for their identity as psychiatrically ill. Compassion for self is difficult to muster. Loss of self-esteem, a sense of alienation, social withdrawal, and self-hatred are common sequelae.

During categorical social cognition, the sociobiological systems stream information about the social world through the rostral anterior cingulate gyrus where it can be compared to a model of expectable reality that has been constructed by the prefrontal cortex from memory retrieval [18]. Detecting a mark of stigma in a person’s environment appears to generate conflict between incoming sociobiological information and an expectable reality. When the anterior cingulate gyrus detects this conflict, a need for additional control is signaled to the prefrontal cortex. The dorsolateral and ventrolateral prefrontal cortices then resolve the conflict by exercising top-down modulation over subcortical systems that constitute the pain matrix, including the amygdala (fear), insula (disgust), and ventral anterior cingulate gyrus (suffering) [17–19]. Activation of the pain matrix produces proximate motivation for avoiding or extruding the bearer of the stigmatizing mark. The flow of mirror neuron information is then suppressed, and person-to-person social cognition fails to activate. Empathy for the stigmatized person is suspended. The stigmatized person is then behaviorally extruded and oppressed, for which the stigmatizer typically feels no guilt ([16], pp. 36–55).

Different types of stigma can recruit different brain circuits and signaling pathways. Moral stigma, for examples, activates circuitry of ventromedial prefrontal cortex that is essential for generating social disgust [20]. Patients with damage to the ventromedial prefrontal cortex lose their aversion to intimate contact with strangers, social deviants, or those bearing misfortunes, such as the poor or homeless, whereas their moral disgust remained intact for those who violated the dignity of others, as with unfairness, cheating, or betrayal [20].

Designing Interventions to Counter Stigma

The goal in stigma management is to move from these categorical processes to person-to-person relatedness, which is organized out of the mirror neuron system and medial prefrontal systems for mentalization and empathy. These “slow” systems from a cognitive processing perspective permit a highly individualized appraisal of another person that includes emotional attunement ([16], pp. 1355). Decety and colleagues [21] suggest that some aspects of physician training and experience may reduce mirror neuron mediated empathy. This suggestion was based on their finding that non-medical participants showed different patterns of event-related brain potentials (ERP) when witnessing people experiencing painful vs. non-painful stimuli, whereas internal medicine physicians showed no ERP differences when watching persons experiencing painful vs. non-painful stimuli. Reciprocal inhibition between person-to-person social cognition and categorical social cognition, which would potentially reestablish some aspects of empathy, provides a major strategy for countering interpersonal stigma. When a personal relationship can be established with another individual, categorical perception of that individual predictably fades from attention. These pathways likely underlie the effectiveness of social contact/exposure anti-stigma interventions that facilitate interaction between potential stigmatizers and persons with mental illness in recovery [5]. Establishing person-to-person relatedness with a potential stigmatizer as quickly as possible is thus a high priority for a person at risk for stigmatization.

A second strategy has its underpinnings in the relationship between high arousal states and a bias towards categorical social cognition. Activation of the anterior cingulate gyrus by perception of a stigmatizing mark not only activates the prefrontal cortex but also the ventrolateral tegmentum (dopaminergic pathways) and locus coeruleus (noradrenergic pathways). These monoamine systems ascend to cortical and limbic regions where their modulation heightens brain arousal, primes the orienting reflex, and re-allocates attention for sensitized detection of marks of stigma [18]. Arousal due to threat, ambiguity, or uncertainty thus produces a shift towards categorical social cognition. Conversely, a lowering of arousal produces a shift towards person-to-person social cognition. Lowering arousal can be achieved by minimizing perception of threat, reducing ambiguity, and bolstering a sense of coherence and predictability about the potential stigmatizer’s circumstances.

Activating person-to-person social cognition, while diminishing alertness to threat, together form the bedrock for building strategies to counter stigma in interpersonal interactions that psychiatrists face in clinical practice.

GWU Residency Seminar on Social Psychology and Social Neuroscience of Stigma

Our George Washington University (GWU) psychiatry residency has created a didactic curriculum that teaches both a scientific knowledgebase for understanding stigma against mental illness and skill-sets for assessing, formulating, and intervening to attenuate stigma. This seminar teaches residents how to manage five types of clinical encounters in which psychiatrists commonly confront stigma.

The 8-week combined postgraduate year-III (PGY-III) and PGY-IV seminar integrates the study of social psychology and social neuroscience research literature with experiential exercises and clinical portfolios of assessment, formulation, and anti-stigma interventions conducted within residents’ clinical settings. A full description of this seminar with learning objectives, readings, exercises, and methods of assessment are available from the authors. Below is a brief summary of the seminar modules.

Module I: Social Psychology and Social Neuroscience of Stigma

Readings from social psychology and social neuroscience literatures teach distinctions between social processes of stereotyping, stigma, prejudice, and discrimination, as well as the clinical use of relevant psychological constructs, such as social identity, identity flags, in-groups/out-groups, and group entitativity. Entitativity refers to an in-group’s level of organization, or “groupiness,” which primes a readiness to stigmatize out-group members. Experiential exercises help residents to apply these constructs to their personal experiences of stigmatization over the course of their lives.

As a group exercise, residents design a hypothetical new stigma by treating as a mark of stigma a selected behavior that might occur within the daily work lives of psychiatry residents. To illustrate this point, we have provided an excerpt from a resident exercise generating a credible stigma utilizing the following four-step “Stigma Generation Exercise”:

1. Think of a behavior that a psychiatry resident could display that plausibly would become stigmatized because it would disrupt the smooth and efficient functioning of residents working together as a group. As a representative behavior, the residents identified introduction of new clinical material for discussion just as end of day sign-out rounds were concluding. Hand-off of patient care to the night call team would then be unnecessarily lengthened by the poor organization and lack of thoughtfulness of the offending resident.

2. What might constitute an identity flag that would enable the rapid recognition of a resident showing this behavior? “Looking through papers”—as the sign-out discussion were ending, the offending resident would begin rummaging through notes from which to re-open discussion.

3. Think of ways that you could think about, talk about, and interact differently with that person so as to convey effectively that a resident with this mark of stigma is discredited as a person and now holds lower status within the whole group of residents. Other residents would “roll eyes” or look away when the offending residents would begin speaking and impatiently would interrupt comments. This could progress to omitting the resident from significant clinical conversations among residents.

4. Think of ways that this stigmatized resident could be discriminated against so that the espirit de corps of the larger group of residents would be lifted or the larger group would function more efficiently and effectively. Over time, invitations to resident social activities, such as “happy hours,” would cease for the offending resident. The resident also would be given “last picks” on switches among residents for weekend or holiday calls.

Residents who participated in the stigma generation exercise were surprised how quickly a credible stigma could be generated (less than 10 min), the intensity of emotion it evoked, and their lack of felt empathy towards the stigmatized resident. The exercise helped make the point that stigma is a social phenomena of normal people, not an indicator for mental illness.

Module II: Helping Patients to Anticipate and Manage Stigma in Family, Community, or Work Place Settings

Residents learn how to assess, formulate, and design anti-stigma strategies by discerning first the stigmatizer’s group of identity. A person who stigmatizes someone acts primarily as a group member whose group of identity has been threatened. Moral stigma, disruption stigma, and courtesy stigma all share in common a sense of threat to the group of identity. Each group conducts defensive surveillance of its social space and does so uniquely depending upon what is perceived as vital to its interests. A strategy to counter stigma begins by appraising the methods a particular group uses to monitor threats to its security. The following four-step assessment prepares the groundwork for an anti-stigma strategy (see Fig. 1, box A).

Fig. 1

Four-step assessment of stigma and application to common challenges in clinical settings

For designing interventions, residents study strategies that have been honed across the ages by individuals stigmatized for their ethnicity, religious beliefs, social class, or other social identity. Applications of these strategies have been validated in empirical social psychology research studies [2]. Figure 1 (box B) includes some of these strategies.

As an exercise, residents practice this assessment process by appraising a psychiatric patient’s risks for stigma, then tailoring an intervention that would anticipate and reduce the risk. This exercise was particularly suitable for inpatients approaching discharge back to home, community, and workplace.

Illustration: Ms. P. was a middle-aged woman admitted briefly to a psychiatric inpatient unit for depression. Conversations with Ms. P. revealed her impending reunion with her family and her return to her workplace to be potential concerns for stigmatization. However, the types of stigma differed. In her family, moral stigma was expressed, more by her siblings who viewed her depression as “weakness,” than by her husband and children. An identity flag in her family was “never asking for help,” and her babysitting requests when she felt overwhelmed had been treated as marks of stigma. At work, disruption stigma was the issue due to concerns that she might not be able to maintain reliable productivity. An identity flag in her office was “staying late until the job is done.” Leaving early from her workday or visits to her psychiatrist had been treated as marks of stigma. The psychiatry resident used role plays to practice with Ms. P. “what to say to whom” about her hospitalization, a plan to manage performance monitoring at work, and engaging her husband’s help in managing her siblings expectations.

Module III: Helping Patients Resolve Internalized Stigma and Its Sequelae

Residents study research literature on internalized stigma with its adverse impacts upon morale, relational lives, and treatment adherence for psychiatric patients. Role plays are used to practice psychotherapeutic strategies for recovery from internalized stigma by discovering aspects of oneself that are unsullied, intact, and worthy, while mobilizing defiance of the stigmatizing inner gaze. In manageable steps, patients practice steps of recovery (see Fig. 1, box C).

Illustration: Mr. D. was mired in social isolation and self disgust for his disability status from a recurrent mood disorder. Over the course of a brief psychotherapy, his psychiatry resident therapist focused detailed attention to the delicate caretaking he had provided for his orchids that were of remarkable beauty. Over the course of therapy, he slowly became able to experience this caretaking as a core sense of his identity, and, in time, to transfer the same care-taking to his personal wellbeing, with heightened self-regard and new relationships with others.

Module IV: Conducting Treatment Effectively Despite Active Stigmatization by Medical Colleagues

When residents feel stigmatized by a patient, patient’s family, or colleague, the residents’ attention focus upon the stigmatizing person’s group of identity, not the patient, family member, or colleague as an individual. The four-step assessment (module II) is conducted to determine type(s) of stigma and how that group’s social surveillance is conducted. Based upon this assessment, a strategy is designed and implemented to counter stigma against the mental health professional (see Fig. 1, box D).

Illustration: As a group, the PGY-III residency class felt most stigmatized, not by patients, but by medical colleagues such as by Emergency Medicine attendings who “hated psychiatry patients.” However, examination of multiple vignettes revealed two unexpected conclusions. First, peril stigma was an issue for some attendings who feared the unpredictable violence that occasionally occurred with psychotic patients. Second, both moral and disruption stigma emerged from hospital rules that Emergency Department attendings held authority to determine admissions for the medical and surgical services, but psychiatric admission decisions were made by the psychiatry resident. Emergency Medicine attendings were reacting both to a slow-down in speed for transferring patients out of the Emergency Department to the psychiatric unit by needing to consult first a psychiatry resident. They also reacted resentfully to what felt like a violation of hierarchy for an attending to ask permission from a resident. The PGY-III class brainstormed different strategies for oncall residents to structure differently how they interacted with Emergency Department attendings to minimize each of these stigma pathways.

Module V: Conducting Treatment Effectively Despite Active Stigmatization by Patients or Their Families—Helping Patients Access Care from Lay, Religious, or Other Healers When Professional Mental Health Treatment Risks Shunning or Extrusion by the Patient’s Group of Identity

Residents practice a four-step stigma assessment for patients or family members who stigmatize psychiatry. Case discussions examine how residents have implemented strategies for the stigmatized psychiatrist in clinical encounters where they have been stigmatized (see Fig. 1, box E). Key aspects of this process include showing empathy for the patient’s predicament, including the patient’s conflict from feeling coerced into meeting with a psychiatrist; expressing “negative goodness” by showing respect for the stigmatizing person’s group of identity and by acknowledging and respecting differences; creating a climate of safety by minimizing perceptions of threat; and meeting the stigmatizing person as a person, not as a category, by learning about the stigmatizing individual as a complex person possessing unique ideas, emotions, and actions. The following vignette illustrates how clinical work can be conducted effectively from a stigmatized position, including efforts to help the patient to find resources within his group of identity ([16], pp. 144–147):

Mr. B. was a young man for whom psychiatric consultation had been requested due to jerking movements diagnosed as psychogenic movement disorder by the consulting neurologist. As the psychiatric consultant entered the room, he sat up vigilantly in his bed, with a hostile demeanor and minimal politeness.

The psychiatric consultant realized that Mr. B. felt humiliated by the presence of a psychiatrist in his care, which was further evident in his vigorous denial of any current life stressors or past psychiatric symptoms or treatment. Mr. B. had struggled with severe diabetes since childhood.

The consultant inquired about Mr. B’s own theory as to the origins and meaning of his medically unexplained symptoms. Mr. B. responded angrily, telling how his internist had confronted him with an abrupt accusation “there is nothing wrong with you,” after medical tests reported normal findings. Mr. B. felt stunned, betrayed, and bitterly angry. He fired the doctor but then felt lost and confused where to turn next. He eventually found his way to the GWU Neurology Department. The consultant observed how Mr. B.’s wariness was diminishing as he spoke from his personal experience. The consultant expressed empathy for B.’s frustration with his medical caregivers, then asked an existential question to draw Mr. B.’s motivations, values, and commitments into the discussion: “You are shouldering a lot—diabetes is a chronic disease that requires more and more care as one grows older, and it must take a lot of work to manage this plus the episodes of jerking, and especially so since the doctors to whom you have turned had been of no help. What has kept you from giving up or being overwhelmed by all this?”

Mr. B. described how he attempted to utilize his religious faith, including counseling from a religious professional, to cope with problems in his life. He had attempted “to beat his body into submission.” The psychiatric consultant kept his formulation of the problem within Mr. B.’s religious discourse:

“Perhaps you are locked in spiritual warfare between your desire to live a life of the spirit and the desires of the flesh. The tension produced might be making your body ill… There might be other possibilities beside beating the flesh into submission or letting the flesh take over… I am concerned that as you have tried to exert tighter and tighter control over your feelings, the struggle and tension has increased, not lessened, and it is making your body ill.”

While this formulation might have provided a reasonable rationale for referring Mr. B. for psychotherapy, the psychiatric consultant also realized that Mr. B.’s conservative religious community would likely shun him were he to go outside the religious community for help. He sought instead to organize a recommendation within resources of Mr. B.’s religious ingroup: “If this idea has any merit, then I would recommend that you work with someone who can understand what you are struggling with, not try to do it alone. Psychotherapy with a mental health professional who understands and respects your faith could be one option. Perhaps seeing a pastoral counselor who understands how a spiritual struggle might make the body ill could be another possibility. I’ll bet you know Christians who do not have this kind of warfare going on within them. If you were to spend time with someone who is older and has lived a lot of years, there might be things you could learn.” Whereas treatment by a psychiatrist or psychologist would be unacceptable within his group, a psychologically mature elder in his church might be better positioned for this role than a mental health professional.

Seminar Outcome Assessment

The seminar began as part of a programmatic effort to ground the GW psychiatry residency in neuroscience research [9]. In its first 4 years from 2009–2012, it was taught at the PGY-III level, utilizing readings and handouts to teach clinical concepts of stigma together with brain circuitry for dual social cognition systems, in similar manner to the current manuscript. However, seminar outcome assessments found that residents had gained significant cognitive knowledge about stigma but were failing to translate it into practical interventions in clinical encounters [10]. The seminar was retired for a year and re-drafted to translate knowledge about stigma into teachable practices.

The current 2014 seminar was taught with 11 PGY-III and PGY-IV residents in a combined group. Residents in this group were all US medical school educated but highly diverse in terms of gender, ethnicity, race, religious identity, and sexual identity. A draft of the current manuscript was utilized as a core text so that residents’ evaluation of the seminar could also serve as a direct evaluation of the teaching model. Readings were completed outside of class, and lecture time for each session was limited to a 15-min review of key principles. The remaining 75 min of each session were fully spent with small group skill-building exercises that practiced stigma assessment, formulation, and intervention for different types of stigma in different contexts, employing role plays and enactments drawn from encounters with stigma in residents’ personal lives, GWU Hospital psychiatric services, or outpatient community clinics.

The educational impact of the 2014 seminar was assessed utilizing multiple methods that included the following:

A. In-Session Observed Assessments of Cognitive Learning—Reviews of core concepts and key ideas were conducted weekly with the full group. For example, residents were queried in group discussions: (1) to define stigma and its key attributes, (2) to explain how stigma is generated via categorical social cognition, (3) to describe the four steps for stigma assessment, formulation, and intervention, and (4) to describe multiple types of intervention strategies.

B. In-Session Observed Assessments of Procedural Learning—Small group memberships were changed weekly. Each group performed four-step stigma assessment, formulation, and intervention exercises utilizing different case examples in role played enactments until accrual of a level of competency was observed.

C. Post-Seminar Assessment of Learning by Individuals— An end of seminar assessment provided confidential feedback from individual residents.

· Global rating for educational effectiveness of seminar was 8.0 (range 6.0–9.0) on a zero-to-ten Likert scale;

· Nearly 50 % of respondents posted positive narrative comments on use of role plays and enactments as training tools;

· Comments for improvements included additional readings, greater structure, and additional sessions per module;

· One respondent requested 10-min decompression time at the end of each session to process difficult emotions that arose during the exercises.

D. Post-Seminar Assessment of Learning with Focus Group—A focus group of all residents was used to identify strengths, accomplishments, and challenges.

· What was any useful new learning that you gained from the seminar? First, learning that stigma against mental illness can exist in multiple different categories, such as peril stigma, moral stigma, or disruption stigma; second, gaining confidence that one can possess tools for managing stigma effectively; third, learning the effectiveness of person-to-person contact in attenuating stigma; and fourth, learning to describe different steps in social cognition that underlie stigma, which provides a way to talk about stigma in clinical discussions.

· In what settings have you employed this new learning? Two outpatient community mental health center training sites were named where residents were making efforts specifically to address internalized stigma among patients with chronic psychiatric illnesses. A resident commented that the seminar let her to become more aware of how she might be perceived by her patients in terms of social categorization. Another commented that the seminar “helped me figure out when I was stigmatizing.”

· Have there been problems or challenges with stigma for which the seminar did not provide sufficient help? The main challenge identified was how to help a patient stigmatized by family members when the family took no role in the patient’s treatment.

· What was your experience of participating in the role plays, enactments, and discussions involving stigma and prejudice? Here, residents’ responses reflected ambivalence. The exercise experiences brought home the power of group identity and categorical social cognition and the emotional impact of stigmatization. One resident commented, “It can be good to remember. You draw closer to people in your group and try to prove the others wrong.” However, another resident said, “It is hard to think about and talk about how I’ve been stigmatized. It doesn’t draw me closer to others,” and another responded, “Learning how to intervene is good, but it brings up a lot of anger that I have to do it.” Several residents told how the exercises that focused on group identity also made them more aware of group identities among the residents, which created a sense of separateness.

In summary, the in-session assessments of learning confirmed by observation the learning of critical cognitive information, as well as procedural learning for stigma management in varied enactments and role plays. The post-seminar focus group assessment demonstrated specific clinical sites and settings where residents were implementing learning in practice, with residents’ reporting specific clinical successes in terms of the following: (1) possessing specific tools with which to counter stigma effectively, which empowered residents’ sense of effectiveness; (2) enabling residents to conduct successfully some difficult clinical encounters that stigma might otherwise have compromised; (3) providing language for describing and discussing stigma as a difficult social process, i.e., “making explicit the implicit” in an inpatient rounds discussion of a case where stigma was impacting patient care; and (4) heightening self-awareness of one’s participation in stigmatizing processes, e.g.,. “helped me figure out when I was stigmatizing.” It is important to note that experiences of participating in training exercises that evoked past personal experiences of stigmatization were felt both to be valuable and emotionally distressing.

Conclusion

Stigma against psychiatry, psychiatrists, and individuals bearing mental illnesses is universal among human societies. Social psychology and social neuroscience can provide an understanding of stigma that yields more effective methods for assessing, formulating, and implementing interventions for countering stigma. This social psychology and social neuroscience perspective helps identify steps in stigma generation where targeted interventions are most likely to be effective. It distinguishes multiple kinds of stigmatizing processes so that interventions can be more specifically tailored. It also helps set more realistic expectations for what can be accomplished with programs of education, which have limited effectiveness with implicit cognitive processes of interpersonal stigma, but greater effectiveness with explicit cognitive processes of institutionalized stigma and discrimination. It is teachable in a residency seminar that blends didactic study with experiential and group-learning exercises. This approach to breaking down stigma into different types of threats and employing social psychology may also benefit public campaigns to reduce stigma against mental illness. To date, public campaigns that use neuroscience to explain the etiology of mental illness have limited and even exacerbating effects on stigma [6]. Instead, social neuroscience theory could be employed with the public as we have done with residents. There is preliminary support for this as evidenced by positive outcomes for an anti-stigma module employing these same principles which we included in a mental health training for police officers in Liberia [22]. Future efforts for neuroscience-based training in reducing and managing stigma should evaluate the impact of these curricula on trainee behaviors, clinical practices, and patient outcomes.

Implications for Educators

Residents need skills sets for countering stigma during interpersonal encounters with stigmatizing patients, families, and medical colleagues.
Curricula are needed to prepare residents to integrate knowledge of neurobiology to reduce stigma, which is a highest tier competency (level 5) for Clinical Neuroscience (milestone 3) in the ACGME Milestones for Psychiatry.
Mental health trainees can be taught to improve managing stigma by categorizing stigma according to peril threats, disruption threats, empathy fatigue, and moral threats.
Effective stigma management strategies incorporate reducing arousal to threat and shifting interpersonal interactions from categorical social cognition to person-to-person social cognition.
Social neuroscience and social psychology research can be used to understand stigma within the healthcare system and to manage stigma against mental health clinicians from medical colleagues.
Further research is needed to evaluate the impact of social neuroscience-based stigma reduction on clinical practices and patient outcomes.

The Impossibility of An Answer