Psychiatric disorders, variously conceptualized, have always been a part of human life. They typically, but not always, are judged as negative differences from so-called “normality.” Along with this judgment, they are often stigmatized to varying degrees and in various ways. As sociologist Erving Goffman argued back in 1963, stigmatization spoils social identity. It has profound negative effects on the stigmatized, leading to social exclusion and other injustices. This is well known and has motivated political movements such as End the Stigma to push for a changed social environment in which psychiatric disorders are not stigmatized (or are less stigmatized). I think this goal is laudable, but I have also found that the social processes behind stigma have tricky dynamics, and some efforts to reduce stigma end up redirecting it rather than removing it. The dynamics of stigma (including human responses to stigmatization) have had epistemic and ontological consequences as well as social and ethical consequences. This means that our current concepts of psychiatric disorder will need to be substantially reconfigured in order to fairly and effectively reduce stigma. The dynamics of stigma are deeply entrenched in our linguistic and social practices.
Those who are stigmatized often develop strategies to minimize the effects of stigma on themselves. Goffman described these strategies as passing, covering, managed disclosure, minstrelization, humor, tact, acceptance, and ambivalence. Passing, covering, and managed disclosure, for example, are well-known strategies for self-protection that reduce the stigma experienced by an individual while leaving the stigmatization of an entire category unchanged. They do so by making the individual’s membership in the stigmatized category unknown or less known. Obviously, this does nothing to reduce the stigma of the category, although it can be helpful to the individual’s efforts to avoid stigma for themselves. The other strategies discussed by Goffman are more complex and sometimes do a little to reduce the stigma of categories: Humor and minstrelization, for example, reduce stigma by reducing perceived threat (fear of those with differences coded as negative increases stigma). I am particularly interested in a strategy that Goffman does not explicitly mention (but it may fall under his category of ambivalence): punching down. Punching down lifts up one somewhat stigmatized category, making it less stigmatized, by implicitly or explicitly distinguishing it from another more stigmatized category. (I borrow this term from comedy culture, which recommends, on moral/political grounds, punching up rather than punching down. It is nicer to make fun of those in positions of power than those in disadvantaged positions. Punching down is like kicking the dog after being treated unjustly in the workplace.)
An example of punching down is the Tourette Association of America’s view that Tourette syndrome should be classified as a neurological rather than a psychiatric condition. To the extent that this is an attempt to destigmatize Tourette syndrome (because it is generally less stigmatizing to have a neurological disorder than a psychiatric disorder), it ends up reinforcing the stigmatization of psychiatric disorders. (The American Psychiatric Association has, fortunately, resisted endorsing this claim because it maintains that at least some psychiatric disorders are also neurologic disorders.) Another example is the common consensus (both lay and professional) about the judgment that grief, even when symptoms are profound, is not a psychiatric disorder (see here, for example). Some authors have even gone so far as to say, “Pathologizing grief is an insult to the dignity of loving relationships—it proclaims grievers as mentally ill”. This statement reveals an underlying assumption that mental illness lacks dignity, again reinforcing the stigma of psychiatric disorders while normalizing grief. Removing a preferred category of persons (Touretters, or those suffering normal grief) from a stigmatized category (psychiatric disorders) reveals ambivalence about such stigmatization—allowing it, even reinforcing it for one category while rejecting it for another. It is a strategy that does not really reduce stigma; rather, it shifts the distribution of stigma. From an ethical perspective, it is an unfair and harmful strategy. From an epistemological and ontological perspective, it is only as good as the arguments for making a distinction between the affected categories.
So far, my examples of punching down have been about negotiating the general category of psychiatric disorder (versus “normality”). There are also many examples of punching down in which what is negotiated is which psychiatric disorder is the right fit for a case, and sometimes this goes along with a demand to create a new diagnostic category because existing categories are deemed too stigmatizing. One example of this is the addition of postpartum depression as a special category in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV, 1994), allowing those who were diagnosed with it to, correctly or incorrectly, avoid thinking of themselves as suffering from major depressive disorder (at the time, this condition was more stigmatized than it is now). Another example is the recent large increase in young adults diagnosed with post-traumatic stress disorder (PTSD). PTSD may be a more acceptable diagnosis than anxiety or depression because the cause is seen as lying outside the individual. A PTSD diagnosis makes it possible to say, “It’s not me; something bad happened to me.” This overlooks the more complex reality that PTSD is caused by a combination of trauma and individual susceptibility to developing PTSD. Those who embrace the diagnosis for themselves may be implicitly endorsing the idea that PTSD is less of a “defect” than anxiety or depression and therefore less deserving of stigmatization. A final example is that schizoaffective disorder is often regarded as a less stigmatizing diagnosis than schizophrenia and is often preferred (by both providers and patients) when there is a choice between the two diagnoses. This does nothing to reduce the stigma of schizophrenia. Schizophrenia may be the most feared and stigmatized psychiatric disorder, at least in the U.S., and its stigmatization worsens outcomes for those with the condition.
When conditions are stigmatized, they become social identities as well as medical conditions. This is why it is attractive to those with stigmatized conditions to try to improve their social identities. Miranda Fricker’s work on hermeneutical injustice has been interpreted as supportive of such efforts for change, suggesting that “Aha!” moments of hermeneutical enlightenment are signs of progress in self-understanding. I think we need to be critical of the degree to which “Aha!” moments signify progress in self-understanding; they may simply be the result of the attractiveness (rather than the correctness) of a new social identity. An example of this is the enthusiasm with which the diagnostic category of Asperger syndrome, proposed by Lorna Wing was received. It was readily embraced by patients and their families as an alternative to the classic autism diagnosis, even though the differences between Asperger syndrome and “high-functioning” autism were never clearly or consistently specified. In hindsight, it has become clear that Asperger syndrome was embraced as a more favorable and less stigmatizing diagnosis than autism and never had much scientific value.
Removing or reducing stigma from psychiatric disorder(s) is thus not a simple matter of withholding social judgments from supposedly descriptive categories, what I call the “grime” theory of stigma, which conceptualizes stigma as a layer of grime covering an underlying fixed painting. The concept of psychiatric disorder as we have inherited it is already imbued with values, some of which we would not reflectively endorse. The same is true of particular psychiatric disorders, as well as psychological conditions that we do not currently regard as psychiatric disorders, like grief. Making progress on destigmatizing psychiatric disorders will take a careful, critical exploration of what the concept of psychiatric disorder should be when stigma is taken out of the equation.
Miriam Solomon
Miriam Solomon is Professor Emeritus at Temple University. Her research focuses on philosophy of science, philosophy of medicine, philosophy of psychiatry, history of science, epistemology, gender and science, and biomedical ethics. She is the author of Social Empiricism (2001), Making Medical Knowledge (2015), and many articles.
