Elsevier

Social Science & Medicine

Volume 64, Issue 7, April 2007, Pages 1524-1535
Social Science & Medicine

Culture and stigma: Adding moral experience to stigma theory

https://doi.org/10.1016/j.socscimed.2006.11.013Get rights and content

Abstract

Definitions and theoretical models of the stigma construct have gradually progressed from an individualistic focus towards an emphasis on stigma's social aspects. Building on other theorists’ notions of stigma as a social, interpretive, or cultural process, this paper introduces the notion of stigma as an essentially moral issue in which stigmatized conditions threaten what is at stake for sufferers. The concept of moral experience, or what is most at stake for actors in a local social world, provides a new interpretive lens by which to understand the behaviors of both the stigmatized and stigmatizers, for it allows an examination of both as living with regard to what really matters and what is threatened. We hypothesize that stigma exerts its core effects by threatening the loss or diminution of what is most at stake, or by actually diminishing or destroying that lived value. We utilize two case examples of stigma—mental illness in China and first-onset schizophrenia patients in the United States—to illustrate this concept. We further utilize the Chinese example of ‘face’ to illustrate stigma as having dimensions that are moral-somatic (where values are linked to physical experiences) and moral-emotional (values are linked to emotional states). After reviewing literature on how existing stigma theory has led to a predominance of research assessing the individual, we conclude by outlining how the concept of moral experience may inform future stigma measurement. We propose that by identifying how stigma is a moral experience, new targets can be created for anti-stigma intervention programs and their evaluation. Further, we recommend the use of transactional methodologies and multiple perspectives and methods to more fully capture the interpersonal core of stigma as framed by theories of moral experience.

Introduction

The construct of stigma has generated extensive theoretical and empirical research, and as the literature has expanded, so too has reasoning about what the concept entails. We trace the development of the stigma concept, paying particular attention to an evolution in its definition from a construct largely grounded in the individual to one rooted in social space. Next we examine theoretical models describing how stigma affects people, focusing on how these models have identified stigma's social aspects. This examination of the limited manner in which current definitions and theoretical models address the social dimensions of stigma reveals a need for an expanded conceptual lens that incorporates moral experience, or what is most at stake for actors in a local social world. We provide several examples of stigma as moral experience, focusing on mental illness in China as an illustration of stigma as a dynamic psychocultural process. We conclude by describing the impact of current stigma theory upon measurement, and detail how consideration of moral experience will encourage innovative means of measuring stigma.

We first examine how existing stigma definitions have delineated this construct, with a particular focus on how stigma's social elements have been conceptualized. Goffman (1963), in his classic formulation, defines stigma as “an attribute that is deeply discrediting” and proposes that the stigmatized person is reduced “from a whole and usual person to a tainted, discounted one” (p. 3). Goffman views processes of social construction as central; he describes stigma as “a special kind of relationship between an attribute and a stereotype” (p. 4) and avers that stigma is embedded in a “language of relationships” (p. 3). In Goffman's view, stigma occurs as a discrepancy between “virtual social identity” (how a person is characterized by society) and “actual social identity” (the attributes really possessed by a person) (p.2).

Emphasizing Goffman's idea of stigma as an attribute, Jones et al.(1984) use the term “mark” to describe a deviant condition identified by society that might define the individual as flawed or spoiled. Although Jones et al. describe the stigmatizing process as relational—i.e., the social environment defines what is deviant and provides the context in which devaluing evaluations are expressed—these authors also emphasize “impression engulfment”—a psychological process located within the individual—as the essence of stigma (p. 9).

Other social psychological formulations have further located stigma as a characteristic of the individual. Crocker, Major, and Steele (1998) also define stigma as occurring when an individual is believed to possess what they describe as an “often objective” attribute or feature that conveys a devalued social identity within a social context. This identity is then socially constructed by defining who belongs to a particular social group and whether a characteristic will lead to a devalued social identity in a given context. Like Goffman, Crocker et al. propose that stigma at its essence is a “devaluing social identity” (p. 505). Yet the authors observe that stigma is not located entirely within the stigmatized person, but occurs within a social context that defines an attribute as devaluing. Also, these authors cite briefly the influence of power in determining one's susceptibility and possible response to stigma.

These social psychological definitions agree that stigma: (1) consists of an attribute that marks people as different and leads to devaluation; and (2) is dependent both on relationship and context—that stigma is socially constructed (Major & O’Brien, 2005). In conjunction with the insights provided by a perspective based on evolutionary psychology (Kurzban & Leary, 2001), these conceptualizations capture many important aspects of stigma. However, these frameworks have also been criticized as neglecting the stigmatized person's viewpoint and as focusing too narrowly on forces located within the individual rather than on the myriad societal forces that shape exclusion from social life (Parker & Aggleton, 2003).

Out of these critiques, Link and Phelan (2001) proposed a sociological definition of stigma as a broad umbrella concept that links interrelated stigma components. Similar to the social psychological definitions, the first four components of their definition—labeling, stereotyping, cognitive separation, and emotional reactions (added in Link, Yang, Phelan, & Collins, 2004)—identify social processes that take place within the sociocultural environment whose effects can be observed within the individual. Yet the fifth component of Link and Phelan's definition—status loss and discrimination—also includes structural discrimination (when institutional practices disadvantage stigmatized groups). Also unique to the conceptualizations considered is Link and Phelan's idea that the stigma process depends on the use of social, economic, and political power that imbues the preceding stigma components with discriminatory consequences. Link and Phelan's definition thus represents a critical step towards viewing stigma as processual and created by structural power. This becomes further illustrated by Das, Kleinman, Lock, Mamphela, and Reynolds (2001) who, amongst others, showed that the issue of power is often lodged in the apparatus of the State, whose agents and agencies can stigmatize entire groups.

Just as stigma definitions have increasingly articulated the construct as one based on social processes, models of how stigma exerts its negative effects have progressively emphasized its social aspects. Examining models of stigma, including identifying whether these models classify outcomes as individualistic or social, further illustrates how the social domain has been conceptualized in how stigma works. In contrast to the paucity of stigma definitions, there is a comparatively large literature describing how stigma affects people; we review this briefly (for further reviews, see Hinshaw, 2005; Major, McCoy, Kaiser, & Quinton, 2003; Schmitt & Branscome, 2002; Stangor et al., 2003; Steele, Spencer, & Aronson, 2002).

Several social psychologists have described stigma as a situational threat; stigma results from being placed in a social situation that influences how one is treated. Jones et al. (1984) conceptualized stigma based on the processes of cognitive categorization—i.e., stigma takes place when the mark links an individual via attributional processes to undesirable characteristics that lead to discrediting. Subsequent social psychological models further incorporate the response of individuals to stigma. Crocker et al (1998) included not only the role of social context in shaping identity, but also how individuals cognitively maintain integrity of the self and actively construct social identity. Major and O’Brien (2005) integrate an identity threat model—i.e., a transactional analysis of stress and coping strategies enacted by the individual (Lazarus & Folkman, 1984)—with stigma. The social elements of Major and O’Brien's theory consist of the immediate situational cues (which convey risk of being devalued) and collective representations (knowledge of cultural stereotypes) that influence appraisal of threat to one's well-being. At the heart of these latter two formulations is the concept that stigma predisposes individuals to poor outcomes by threatening self-esteem, academic achievement, and mental or physical health.

Other social psychologists have described stigma as a specific application of stereotyping, prejudice, and discrimination research (Ottati, Bodenhausen, & Newman, 2005). Here, the social elements of stigma consist of socially shared cognitive representations that inaccurately associate individuals with mental illness with certain negative characteristics. Further, the negative emotional reactions (prejudice) or negative behaviors (discrimination) of stigmatizers can be seen to derive from social ‘others’. Paralleling this community model, Corrigan and Watson (2002) present a social-cognitive model of personal response to stigma that initiates when individuals with mental illness know of the negative cultural images that characterize their group (self-stereotyping), which then leads to self-prejudice and self-discrimination. Further, in determining the individual's personal response to stigma, Corrigan and Watson identify social elements such as collective representations (cultural stereotypes, perceived social hierarchies, and sociopolitical ideology) activated by cognitive primes (information from the situation) that influence whether the stigma encountered is appraised as legitimate or illegitimate. Like the other social psychological models, Corrigan and Watson locate the primary effects of stigma on the individual's emotional response and self-esteem.

Although the full scope of these social psychological models are too intricate to review here, these models have greatly advanced our understanding of how an individual's stigmatized social identity is constructed through cognitive, affective and behavioral processes. Because these models derive from social psychological theory, each focuses on current social or situational determinants of stigma. Another important emphasis is that stigmatized individuals actively cope—i.e., through construal, appraisal or other cognitive strategies—with stigmatizing circumstances. However, an analysis of these models reveals that they primarily regard the social aspects of stigma as a psychological variable (i.e., ‘social identity’ as applied to an individual), as an environmental stimulus that the individual appraises or responds to, or as societal or cultural stereotypes. Further, these models restrict the range of coping responses to the stigmatized individual's reactions (e.g., cognitive coping strategies) and the harmful outcomes of stigma to individual self-processes (e.g., psychological well-being). These models suffer from limiting conceptualization of the social to those environmental elements of stigma that ‘impinge upon’ the individual sufferer, who is then viewed as the primary locus in which stigma processes take place.

Goffman (1963) did not appear to emphasize such an individualistic focus when he described stigma as a process based on the construction of social identity. Rather, stigma occurs through what Goffman terms a “moral career” (p. 32): when a stigmatized person initially learns society's standpoint and gains a general idea of what it might be like to possess a particular stigma. Persons with mental illness (a non-visible stigma) thus pass from “normal” to “discreditable” status, and if they disclose their condition, a “discredited” status. Goffman describes transition from each status as resulting from “control of identity information”. Thus, in Goffman's view, stigma occurs as a new social identity is assumed through interaction (i.e., “re-identifying”) with socially constructed categories.

Other sociological models have also regarded stigma from a symbolic interactionist perspective. Scheff (1966) proposed a “labeling theory” of mental illness where the application of deviant labels to individuals led to changed self-perceptions and social opportunities. According to Scheff, mental illness stereotypes are learned during socialization and reinforced daily. Scheff proposes that once fully inculcated, the stereotyped “patient” role may then emerge as a “master status” due to its highly discrediting nature (Markowitz, 2005). Uniform responses from others (such as social exclusion) then block attempts to return to “normal” social roles. Link, Cullen, Struening, Shrout, and Dohrenwend (1989) elaborated upon Scheff's claim that the labeling process was the primary cause of symptomatic behaviors by formulating a “Modified Labeling Theory” that proposed that labeling places individuals with mental illness at risk for negative outcomes that may exacerbate pre-existing mental disorders. According to Link et al., expectations of devaluation become personally relevant once official labeling occurs during contact with treatment. Negative psychosocial consequences may stem from beliefs of anticipated rejection or the individual's response to stigma, which are then seen to increase vulnerability to future psychiatric relapse.

Both Scheff's and Link et al.'s models define stigma as operating primarily in the social sphere—the symbolic interactionist perspective proposes that objects in the social world (persons and actions) obtain meaning through social interaction (Mead, 1934). Thus, the meaning of behavior (and deviance) is continuously interpreted through utilization of language and symbols. Social responses to behaviors are shaped by shared cultural meanings. Self-conceptions thus arise from perceptions of how others view and respond to the self as a social object (Markowitz, 2005). “Role identities” (e.g., being “mentally ill”) form when self-conceptions result in reified social positions that are accompanied with behavioral expectations. Despite the emphasis of these sociological models on the social and interactive bases of stigma however, research utilizing these frameworks has largely continued to locate stigma's effect within the individual stigmatizer or recipient.

A subsequent framework proposed by Corrigan, Markowitz, and Watson (2004) further expands the social mechanisms of stigma by describing the structural determinants of mental illness stigma that arise from economic, political, and historical sources. Intentional institutional discrimination occurs when the decision-making group of an institution intentionally implements policies that reduce opportunities for a particular group (e.g., state legislatures restricting people with mental illness from voting). A second type of structural discrimination takes place when policies limit the rights of people with mental illness in unintentional ways. For example, societal policies that limit public mental health care are typically motivated by arguments that increased mental health coverage would lead to prohibitively high health care costs. What is key in structural discrimination is that the decision to stigmatize does not take place at the interpersonal level. Rather, discriminatory policies exert their adverse effects via broader, systemic forces.1

Section snippets

Moral experience and stigma

Sociological approaches push us to conceive of stigma as a social process with multiple dimensions. Stigma is seen to be embedded in the interpretive engagements of social actors, involving cultural meanings, affective states, roles, and ideal types. A social dialectic of interpretation and response effectively ensures that marginalization is perpetuated, since others respond to a stigmatized individual as someone already burdened with shame, ambivalence, and low status. Macro-social structural

Contributions of “moral experience” to stigma measurement

Several useful questions for research emerge from considering moral experience in relation to stigma processes:

Conclusion

Consideration of the practical engagements of preserving what matters most can greatly enliven our understanding of how stigma pervades the life worlds of the stigmatized. From the vantage of moral experience, both the stigmatized and stigmatizers are seen as grappling with what makes social life and social worlds uncertain, dangerous, and terribly real. We hope that future use of this concept and its methodological applications to examine stigma will further illuminate how stigma is

Acknowledgements

Preparation of this manuscript was supported in part by NIMH grant K01 MH 73034-01 which has been awarded to the first author. The authors would like to thank Kim Hopper and Janice Jenkins for their insights and critiques of this manuscript. Further, the authors would like to thank Peter Benson for contributing insights to the framing of moral experience.

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