In my opinion ...

Is "stigma" the right word?

By Otto F. Wahl, Ph.D., Director, Graduate Institute of Professional Psychology, University of Hartford
First published in the Spring 2003 Memorandum of the Resource Center to Address Discrimination and Stigma (http://www.adscenter.org/memoranda/indexspring2003.htm)

 "Stigma" is a term that has long been used to refer to a mark or label that leads to a person being discredited and devalued in the eyes of his or her community. Work by social scientists has established that "mental illness" is such a label. It is well established that people diagnosed with psychiatric disorders face negative attitudes and poor treatment by others. Whether to continue to refer to this phenomenon as "stigma," however, has become a subject of considerable debate recently.

Some people have expressed concern that the term itself may be stigmatizing. Repeated use of the term "stigma" in conjunction with "mental illness," it has been noted, may establish stigma as an element of mental illness - as inevitable and intrinsic to psychiatric conditions. The pervasive verbal attachment of "stigma" to "mental illness" thus parallels and reinforces the social attachment of stigma to psychiatric disorders. Moreover, when the term "stigma" is so rarely applied to health conditions other than mental illnesses, such usage may also reinforce a damaging perception of mental illnesses as wholly different, and less acceptable, than those other conditions.

In addition, some uses of the term "stigma" seem to imply that "mental illness stigma" resides within the individual rather than having been imposed unfairly by society. Dictionary definitions, which often fail to note external imposition (e.g., Webster's "a mark of disgrace or infamy, a stain or reproach, as on one's reputation"), support the concern that stigma may be seen as a flaw of the individual. Even Erving Goffman's scholarly attempt at defining stigma - "an attribute that is thoroughly discrediting" - carries with it the implication that stigma is a trait, a characteristic intrinsic to the individual.

A legitimate concern, then, is that repetition of the term "stigma" in connection with "mental illness," with the implication that stigma is a property of the mental illness, may perpetuate a perception of people with mental illnesses as lesser, fundamentally flawed, citizens.

A related concern is that the term "stigma" does not direct blame for the disenfranchised status of those with psychiatric diagnoses where it belongs and does not call for social change in the same way as do terms such as "prejudice" and "discrimination." Prejudice is something that is recognized as wrong and unacceptable. When this term is used, people understand that the fault is with others, not with the target of the prejudice. The term "stigma" does not carry this message as clearly. Since unfair and unfounded negative attitudes toward a group of people based on stereotypes and misunderstanding are what we are talking about with mental illnesses, prejudice is both an appropriate term and one that directs people toward consideration of their own biased views.

Similar arguments have been presented for using the term "discrimination" rather than "stigma." Discrimination is easily recognized as both unacceptable and the fault of its perpetrators rather than its targets. Moreover, some believe that it is public actions - more than the beliefs or misunderstandings that may underlie them - that need to be the focus of change efforts. They suggest that it is denied opportunities, not negative public attitudes, that create the greatest barriers to meaningful recovery from mental illnesses.

In addition, discrimination can be attacked with legislation and litigation to compel changed behavior. Stigma cannot be similarly prohibited by law. Furthermore, use of discrimination terminology allows one to frame the issue in terms of rights rather than desires. It is not simply a matter of people with mental illnesses wanting and requesting respectful treatment, but of people claiming their legal and civil rights.
As sensible as the above arguments are, however, it is my own opinion that we should not abandon the term "stigma" in favor of "prejudice" and/or "discrimination." My reasons are as follows:

First, the term "stigma" has a historical context that should not be forgotten. The term comes from the practices of the ancient Greeks who branded their slaves with a visible physical mark, a stigma, to be sure that others knew at a glance that the marked person was not entitled to the same privileges as other citizens. Thus, the Greek word "stigma" does convey the imposition of a disenfranchising mark, one we would clearly recognize today was unfairly imposed and not relevant to the human worth and dignity of those to whom it was applied. The term represents the subjugation of worthy people by those in power and the arbitrary assumption of inferiority based upon an assigned marker. Rather than conveying that the problem is within the individual, then, the term "stigma" should remind us how imposed markers can be unjustly used to deny social and community status.

I also believe that stigma is a broader concept than discrimination or prejudice and that the latter terms cannot capture all that we should be considering. Stigma involves not just negative emotional biases toward those with mental illnesses (prejudice), but also language and images that foster misunderstanding and devaluation even when communicators do not see their messages as relevant to mental illnesses. Stigma, in my view, involves not only behavior that denies rightful opportunities (discrimination), but also quite legal behavior that nevertheless hurts and offends and demoralizes. Moreover, the broad category of stigma may encompass the internalized attitudes that people with mental illnesses sometimes adopt from society about themselves and that may lead to self-fulfilling prophecies of demoralization and failure.

I also think that using the term "stigma" may help others to acknowledge their contributions to the problem and to change their behaviors. While the terms "prejudice" and "discrimination" have the advantage of placing the onus on those who display them, they are also harsh terms that may generate more defensiveness than understanding when they are used. People may be able to accept that they contribute in some ways to stigma, especially when that contribution is inadvertent, but they may resist the accusation that they show prejudice and discriminate against those who need their understanding and support.

Finally, the term "stigma" has a research history. The negative attitudes and behaviors of the public toward people with mental illnesses have been studied extensively, and access to that research (e.g., through computerized databases) would most efficiently be accomplished by use of the keyword "stigma." Similarly, current and future work on these issues can most effectively be tied to the previous work on which they build by referencing "stigma" in their texts or titles. While this is a minor consideration relative to the impact of terminology on removing or perpetuating public misunderstanding, it is nevertheless one of modest practical significance.
Given all of the above, my preference is to continue using the term "stigma," but, at the same time, to connect that term more frequently and more deliberately with the terms "prejudice" and "discrimination," as others have suggested. In my own work, I will endeavor to include more use of the latter terms to encourage thinking in terms of rights and imposition.

My mind is not set on this matter, however, and I believe it is important that we continue to discuss the issues of language and its impact. I readily acknowledge that words have power and that we must be careful to avoid terminology that misleads or undermines our own intentions. However, I also believe that it is important for us not to devote so much of our attention and energy to questions of terminology that we neglect the larger issues to which such terminology refers. Although words are important, it is more important that, whatever words we decide to use, we manage to join together to overcome the ignorance, misunderstanding, prejudice, discrimination, and self-stigma that undermine recovery of people with mental illnesses.