Stigma is relative, socially and culturally determined, and dynamic. Consequently, stigma is a difficult concept to operationally define. This is important because definitions shape and directly impact efforts to research and reduce stigma. In 2014, the RAND National Defense Research Institute published an extensive assessment of stigma-reduction strategies within the DoD (Acosta et al., 2014). The first goal of the report was to operationally define mental health stigma in the military context. Interestingly, researchers conducted a systematic literature review and found that more than half of the articles reviewed did not define stigma, many others used inexact definitions, and 98 used distinctly different definitions. Thus, the lack of conceptual clarity is pervasive and poses a challenge for those seeking to analyze stigma.
Kleinman and Hall-Clifford (2009) comment that the modern understanding of stigma is largely owed to Erving Goffman’s articulation of the concept in the 1960s. Goffman viewed stigma as a psychological and social process based on the construction of identity, in which persons who become associated with a labeled or stigmatized condition pass from a “normal" to a “discredited” or inferior social status (Goffman, 1963). The authors highlight that the current definition of stigma over focuses on the psychological impact of stigma and under-examines the sociocultural environment that determines and shapes the distribution of stigma. In addition to psychological and macrosocial components of stigma, the authors assert that research must focus on the social standing of individuals and groups within the morals and values of their local context. Since those who stigmatize and the stigmatized are interrelated in their local social worlds, Kleinman and Hall-Clifford (2009) emphasize the importance of understanding how values unique to the local context impact stigma.
This notion of stigma-in-context is precisely what the 2014 RAND report attempted to capture by defining mental health stigma as: “a dynamic process by which a Service member perceives or internalizes this brand or marked identity about himself or herself or person with a mental health disorder. This process happens through an interaction between a service member and the key contexts in which the Service member resides.” The key contexts identified were the public (i.e., military culture and norms), institutional (i.e., military policies, programs, and treatment systems), social (i.e., friends, family, and unit) and individual (i.e., Service member). Although I would argue that the latter half of the definition and the ecological conceptual model adequately captures the intersecting systems involved in determining mental health stigma, the language of the former half still emphasizes the perception of the individual, the stigmatized.
According to the RAND report, the DoD has made a determined effort across all branches to reduce stigma, primarily by targeting the public context, followed by the individual context. These efforts have contributed to a general decline in perceived stigma among Service members. However, the perception of stigma remains high among those Service members with mental health disorders, suggesting interventions in these contexts need to be more targeted. Additionally, there were very few DoD strategies that focused on the military or institutional context, which, according to Kleinman and Hall-Clifford (2009) is the most important point for intervention. For example, RAND researchers conducted a systematic assessment of DoD policies and found 203 policies contained language that may reinforce negative stereotypes of those with mental health disorders. Specifically, researchers identified ambiguities in language, conflicting language, and negative terminology in policy language that may increase stigma and opportunities for discrimination.
The 2014 RAND report acknowledged that stigma reduction is only one approach in promoting the well-being of Service members and treatment-seeking among those with mental health concerns. Researchers also recognized the problem with focusing on stigma only. Since stigma is so frequently associated with the stigmatized rather than the groups or institutions that promote stigma, some have questioned the utility of the term. In fact, many experts maintain that the mere mention of stigma in conjunction with mental health only perpetuates stigma. For example, by focusing this blog on stigma in the context of mental health, I may be colluding in the unfair stigmatization of those with mental health disorders. Saying those with mental health disorders carry a stigma is to suggest that the problem lies with those who have a mental health disorder and not with those who propagate and maintain negative stereotypes and discrimination (Oliver, 1990; Sayce, 1998; Chamberlin, 1997).
Researchers for the 2014 RAND report proposed the DoD move away from focusing only on stigma-reduction strategies and shift to a multipronged approach to improving treatment-seeking and reducing barriers to mental health care. First, they proposed changing policy and educating those in key contexts to reduce discriminatory behavior among Service members and leadership (who often create the local cultural context). They also proposed increasing training and education programs and exposing Service members to fellow Service members who are in recovery from mental health disorders. Additionally, they recommended using evidence-based cognitive techniques and psychoeducation interventions on an individual level. Such efforts, along with more comprehensive policy revision, target each context and reshape the values that can contribute to barriers to treatment-seeking.
To echo the sentiments of my colleague, Dr. Kelly Chrestman and her blog Beyond the Stereotypes of Stigma, in order for us to end the collective association between stigma and mental health, it might be time to change our language altogether and address institutional and societal prejudice as oppression or discrimination. Such a change may actually shift the burden of responsibility from those with mental health disorders to the local and macro sociocultural contexts that discriminate against them.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Kaleigh E. Flanagan, Psy.D., is the Center for Deployment Psychology’s Military Internship Behavioral Health Psychologist at Tripler Army Medical Center, Honolulu, HI.
Acosta, J. D., Becker, A., Cerully, J. L., Fisher, M. P., Martin, L. T., Vardavas, R., Slaughter, M. E., & Schell, T. L. (2014). Mental health stigma in the military. RAND Corporation. Retrieved from https://www.rand.org/pubs/research_reports/RR426.html
Chamberlin, J. (1997). A working definition of empowerment. Journal of Psychiatric Rehabilitation, 20 (4), 43-46.
Goffman, E. (1963). Stigma: Notes on the Management of Spoiled Identity. New York: Prentice Hall.
Kleinman, A., & Hall-Clifford, R. (2009). Stigma: A Social, Cultural, and Moral Process. Journal of Epidemiology and Community Health, 63 (6). Retrieved from http://nrs.harvard.edu/urn 3:HUL.InstRepos:2757548
Oliver, M. (1990). The Politics of Disablement: A Sociological Approach. New York: St. Martin’s Press.
Sayce, L. (1998). Stigma, Discrimination and Social Exclusion: What’s in a Word? Journal of Mental Health, 7 (4), 331-343.