Fighting Stigma’s Infection Requires Getting to Its Social Roots

The behavioral healthcare field focuses on stigma as a knowledge problem. The dominant approach to ending stigma is to advance a medical understanding of shamed conditions. The public is encouraged to see that major mental illnesses, addiction, and other behavioral conditions are diseases. Medical research will conquer these diseases, and stigma will presumably be eliminated in the process.

Our moralistic status quo denigrates behavioral conditions. These cultural stereotypes will presumably be swept away with a commitment to the modern medical enterprise, dissolving stigma in the course of conquering disease. However, this faith in medicine is overly optimistic. Stigma is not the product of a misunderstanding. Ending stigma is not an ancillary benefit of the medical juggernaut.

Eliminating stigma will require dismantling the social structures and cultural messages that sustain it. Stigma causes suffering independent of any disease. Society marks certain qualities with disgrace, and this is a separate problem to be resolved as such. Stigmatized conditions are primarily clinical problems to be resolved clinically. Stigma itself is a social problem to be resolved through social means.

Societies establish preferred and stigmatized groups based on social power. Social hierarchies are durable. People rise or fall in the social order based on their actual contributions and on manufactured bias and prejudice. While clinical conditions may be the fodder for stigma, the social forces of competition, intolerance, and discrimination better explain how and why stigma thrives.

Consider the experiences of individuals and families suffering from stigma. The destructive impact of major mental illnesses (e.g., various thought and mood disorders) is distinct from the shame and humiliation of social rejection for aberrant behavior. Similarly, the disgrace of addiction can be as painful as addiction itself. Both erode the self-esteem and functioning of the afflicted individual.

We may be setting up our patients and their families for disappointment to the extent we assure them all is well by forging ahead with medicalization. Independent of whether our hopes for medical solutions prove well-founded, we are making assumptions in the realm of the social sciences that are large and untested. The intransigence of stigma is a social reality, not a medical one.

The fight against stigma will likely fail until we recognize its roots. It is a social injustice. It certainly creates distress, but that distress must be understood at individual and social levels. Fortunately, our field is ready for this. We can focus effectively on both clinical and social goals. The social focus is new for many, even though the study of gender, ethnicity, and marginalized groups has a long tradition.

Ending stigma requires a robust plan. This may include changes in healthcare and public education. However, stigma involves harmful social processes rooted in stereotypes and prejudice. It produces ostracized groups and social inequality. The disease concept offered by medicalization is a weak assault on these phenomena. Stigma is a clinical infection with virulent social roots.

Stigma’s emotional damage is ample reason to prioritize it, but its role in suppressing care access makes it an even higher priority for our field. We need a renewed sense of urgency about reducing the enormous treatment gap for our field. Would it be more of a public outrage if another medical specialty had a gap of this magnitude between those needing and getting care? Is this the work of stigma too?

Stigma will only end when we target the conditions allowing it to flourish. Behavioral leaders are increasingly realizing social justice is part of their mission. This may involve aiding marginalized groups who lack behavioral resources. No less important are stigmatized groups who are driven by shame away from needed services. These are thornier responsibilities than celebrating the medical model.

These are challenges that everyone in our field should embrace, but our executives are better suited than others to promote an agenda for social and cultural change. Clinicians focus on change one person at a time, but executives are prepared to change healthcare institutions. For example, they can normalize behavioral conditions by bringing care into the non-stigmatizing offices of primary care.

A biopsychosocial view adds value to a more narrow medical approach by calling attention to social context. We need a social perspective to highlight problems like stigma and health inequities as critical targets for change. Clinicians may understand how social factors shape clinical issues, but executives can see how changing healthcare institutions might improve the health of populations.

Stigma is a primary social problem, and its clinical infection impacts individuals and populations alike. Population health will rise if we can change how stigma suppresses care access. Executives are prepared for change at this level. They often make decisions impacting social groups and institutions. It may be time for medical leaders to pass them the baton for directing stigma’s demise.