Updated: Jan 5
Stigma, discrimination, and shame are words we hear in the discourse around mental health.
Even the term mental health has a strange stigma around it – we loosely say mental health when we mean mental illness.
The Mental Health Productivity Commission Inquiry report recently brought a focus on stigma and discrimination recommending a National Stigma Reduction Strategy. This is a good thing.
Chapter 8 of the report, Social Inclusion and Stigma Reduction, deals directly with stigma and discrimination and is worth a read.
The report didn’t speak too much about shame, which brings me to ponder on the link between shame and stigma and to question if there is a difference between stigma and discrimination?
How do we make sense of the similarities, links, and differences between these powerful words and concepts? What more do we need to understand about what lies beneath stigma, discrimination, and shame?
A common understanding is that stigma occurs when someone or society sees you in a negative way, say because of mental illness, and that discrimination is when someone treats another unfavourably because of the mental illness. That seems simple enough, but does it tell the full story?
The origins of stigma and discrimination lie with the concepts and deeply held beliefs of “you are different to me” and “you are less than me” which lead to acts of discrimination, oppression and othering.
Those acts of discrimination reinforce a sense of being different and not being valued.
It is the acts of discrimination that lead to feeling less than others, the marginalisation, and shame and self-stigma.
The experience of stigma is internal and can lead to feelings of shame, it is what we say about ourselves – how we internalise the exclusion, discrimination, and oppression of society.
Erving Goffman wrote about stigma in the much cited Stigma Notes on the Management of Spoiled Identity (1963) saying “stigma is an attribute that is deeply discrediting” having the effect of reducing someone “from a whole and usual person to a tainted, discounted one” perceived as having a “spoiled identity”.
The idea of “spoiled identity” is surely as disabling as any symptom of mental illness.
The effects of stigma, as described by Goffman, ran through the initial empathy interviews conducted by this project – concepts of not being “outed” or stigmatised were consistent.
What do we mean by not being outed? It directly refers to the actions of well-meaning others, friends, family and frequently, service providers. It could also mean being exposed.
Often, someone will make a call on behalf of the person with a mental illness or psychosocial disability to introduce them, to organise something for them or make things easier for them. The effect can be that it instantly identifies and brands the person with a label and can lead to further discrimination and exclusion.
As we spoke about in our earlier blog On Uniforms, Lanyards and Keys – there is an unfavourable impact from a person being out in the community, identified by being with a worker or helper in a uniform. There is a risk that it tells all that I am less than, not quite complete or indeed a “spoiled identity”.
We have come to recognise that there is a problem in society, that the label or diagnosis have become stigmatised and that people who experience mental illness also experience high levels of discrimination and distress. It is imperative that we act on this.
Our challenge is to understand how.
One recognised way is to provide information and education campaigns that challenge the stereotypes and teach society how to be more embracing of each other. Perhaps, in order to address stigma, discrimination and shame, this needs to be less about what the diagnosis and labels mean, and more about challenging our perceptions of other human beings and what it takes to be a valuable and included citizen. How difference and diversity of thought build the fabric of our society.
As health and community service professionals we also need to recognise that we are part of the same society that is enmeshed in the discrimination and othering. We need to look deep into our explicit and implicitly held world views and practices, ensuring that we are not offering service responses that reinforce to someone, their sense of difference/stigma.
Not being heard was another theme that came through the project empathy interviews, not being heard feeds internal stigma and the sense of not being good enough or worthy enough to be listened to and heard. There is a risk that, in our efforts to help, we compound the effects of stigma and shame.
We often say stigma when really, it is an act of discrimination and othering.
For a number of years, I worked handling complaints of discrimination under Commonwealth and State legislation. I saw first-hand where unlawful acts of discrimination show up. They show up in the most ordinary aspects of our lives - education, work, housing, direct service deliveries, at the bar, at the shops, at the doctors, and many more. Sometimes, the act of discrimination is direct, sometimes indirect, sometimes intentional, and sometimes not. It does, however, always have an impact, particularly for the person already living under a cloud of self-stigma.
International and local laws are enshrined to guide our actions and prevent discrimination. These laws, based on conventions like the Convention on the Rights of People with Disability, recognise the dehumanising and debilitating effects of discrimination and set a frame for us to work to.
How do we make sure we hold true to those laws in our daily lives?
Shame is pervasive and destructive, robbing us of belief in self and of being deserving of a rightful place in society. It’s internal and comes with the echo of external cries of “shame on you”, “shame job”, “shameful”. It’s something we breed and feed within ourselves.
Brene Brown writes powerfully on shame.
“Shame”, she says, “is the intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance and belonging.”
The strength of her work is in the combination of her own personal experiences and vulnerability, as well as her extensive academic research. She has brought a discussion on shame accessible to all in her writings and talks. She offers ways to deal with shame so that it doesn’t suffocate us.
Shame, stigma and discrimination come from the way we shape our society as we compare and contrast each other - they also come from things that may have happened in our lifetimes. It’s all part of life’s rich tapestry as they say – however it does not need to become part of our collective and societal responses. We can change the way we view and respond to experiences of mental illness and mental ill-health.
In this project, Mind-Life’s main assumption is that social exclusion is caused less by the symptoms of mental illness and much more about the reduced opportunities to exercise human rights and live extraordinary lives.
Considering how to address and respond to the stigma and discrimination that many who experience mental ill-health encounter, it is also worth us paying attention to the effect shame has in all aspects of our relationships, society and service systems.
Brown says the antidote to shame is empathy. Empathy can be learned, and as Brown says, “empathy is cultivated by courage, compassion and connection”.
It makes me wonder, is the antidote to stigma and discrimination also rooted in empathy. Is it empathy we need to teach?
We are called to look to how we can change the structures of society that exclude.
How do we see our sameness rather than our difference?
How do we build empathy in all our lives and actions?
What are we prepared to do to challenge the inherent biases and prejudices that exist in society?
Productivity Commission 2020, Mental Health, Report no.95., Canberra
Goffman. E. (1963) Stigma; notes on the management of spoiled identity. Englewood Cliffs, N.J.: Prentice Hall
Brown, B.(2007) “I thought It Was Just Me (but it isn’t): Making the Journey from “What ill People Think?” to “I Am Enough”. New York, USA: Penguin