The power of stigma

Stigma is a very powerful mechanism. It is the expression of an old coping strategy sometimes very efficient for survival. It serves to identify, and to do it forever, a danger. In order to do so, a characteristic of the danger becomes a distinctive mark, or the bearer is marked, often forcefully.

Stigma is the consequence of prejudice and prejudice is detriment or damage, caused to a person by judgement or action in which his/her rights and dignity are disregarded. Prejudice leads to action, and this action is to stigmatise.

Stigma is a brand. To brand is to mark indelibly as a sign of quality. To brand is also to impress indelibly on one's memory, therefore the stigma is both in the stigmatised person and in the stigmatising one.

Stigma comes from the Greek word στγμα, 'mark', which is related to the word στζειυ, i.e., to tattoo, to prick, to puncture. In Latin it became instigare, 'to urge'; therefore, stigma also leads to action, and this action is discrimination against the stigmatised person. To discriminate is to make adverse distinctions with regards to those stigmatised, and to make distinctions prejudicial to people different from oneself (in race, colour, or sanity). Here the vicious circle is closed, because discrimination leads to prejudice, prejudice to stigma and stigma to discrimination.

Animals too stigmatise. Especially those living in woods mark their territory with signals on trees. Birds too mark their territory with their singing, but the closest to human beings is the cat. Allow me an anecdote. Nisse da Silveira, a Brazilian psychiatrist, devoted her life to the study of the artistic production of mentally ill patients, mainly those with chronic schizophrenia. She worked in the Rio de Janeiro Mental Hospital, which at her time was crowded with cats. She was very fond of them and one day she compared them to me with her patients. Cats rub themselves against human beings, leaving in them the odor of glands they have along their neck. The odor depends on which part of the neck they use to rub, and there are odors for friends and others for enemies. Once a cat has identified a person as a friend or enemy, the odor embedded on him or her marks this person forever. The same happens with patients with schizophrenia. Nisse told that if someone is recognised as a threat and forms part of the delusions of a patient, he or she will remain so forever. The opposite is true also.

This anecdote reveals two important things. First, the mark is embedded on the subject, and from then on it stays there. The 'marker', the stigmatising person, loses the control of the situation, which from then on is imposed on him. Efforts to remove the mark will lead to make it more prominent and to acquire other negative elements.

The second point is that the response to stigma is stigma; stigma is given back as stigma. Cats, and patients with schizophrenia, stigmatise people and are, specially patients, stigmatised themselves. This fact is so prominent and relevant that once I thought of writing a paper entitled "Schizophrenia or stigmophrenia". The behavior of stigmatising normal persons towards patients with schizophrenia is the same that patients have towards their delusions. In both cases it consists of something which is experienced as imposed, self-evident, full in certainty, irrefutable to a logical line of argument, as in the old definition of delusion.

This is not new. In the late 1960s, Siegle and Osmond (1) described the models of madness, that is, the basic approaches to conceptualise madness. They described seven of them: medical, psychoanalytic, moral, familiar, social, psychedelic and conspirational. Then, the anthropologist Hsu (2) commented that curiously enough, those same models shape the delusions of patients. The consequence is that, when confronted with madness, the one which may afflict oneself or the one perceived in others, the answers are the same.

The Spanish psychiatrist Sarró (3) devoted his life to study the contents of delusions. He came to the conclusion that delusions are built with the same elements as myths. In total there are 24 themes of delusions and of myths (mitologemas in Sarró's words), and all of them are an explanation to the basic facts of life: birth, death, transitions, gender, and so on. The confrontation with madness is terrible indeed. Madness is conceived as the loss of one's own mind, and this is the source of great anxiety. Fear of dying and the fear of losing the mind are the two basic forms of anxiety (4), because they are the expression of the fear of ceasing to exist, physically or mentally. Anxiety sets up coping mechanisms, not all of them adaptive. The psychologist Kunz (5), many years ago, tried to find a normal mental phenomenon which had the structure of delusions. He found one, the idea of death. Unable to experience death without dying and full of fear of the unavoidable fact, human beings tend to externalise it, to objectify it, to deny it, the same mechanisms which are present in delusions.

Psychiatry has done a great effort to delineate normal from abnormal mental events, following the path of the rest of medical disciplines. At the end, psychiatry has been able to identify the symptoms of madness, something essential in order to reach a diagnosis and to take decisions on the best therapeutic options. But this should not lead to abandon another, essential, perspective, which is to delve into the meaning of psychiatric disturbances and to look for common structures with normal mental phenomena. This is a way to understand underlying adaptive mechanisms.

The prevailing notion that delusions have a structure different from normal thinking was recently challenged. For instance, Hillman (6) and Blankenburg (7), among others, have reached the conclusion that this is not the case. If the difference does not lie in the structure of the delusions, if both patients with delusions and the rest of us use the same procedures to grasp reality, to build the world in which we live and to endow it with meanings, stigma becomes an essential aspect of mental diseases. Therefore, the fight against stigma becomes an essential part of the fight against mental diseases. It is not just the need to overcome barriers for care, it is essential to recover mental health. In other words, the barriers that sane, including psychiatrists, build to protect themselves against insanity are barriers that the insane has to overcome to recover his or her sanity.