A stigma perspective on recovery

Recovery, as outlined by Bellack and Drapalski, describes a process through which a person aims to live “a satisfying, hopeful and contributing life even with limitations caused by illness”, striving for “full human potential or ‘personhood’”. It is thus about healing identity, and somehow it sounds like a positive, optimistic echo to the spoilt identity observed by Goffman (1963) in his classic work on stigma 1. In many ways, “recovery” and “stigma” seem to be related, but contrary concepts. While recovery claims a “half full” glass of opportunities, stigma points out the “half empty” glass of discrimination and devaluation. Where recovery sees challenges, stigma identifies obstacles. Is “recovery” thus just a new, positive way to describe the same ongoing struggle of persons with mental illness for a better life?

Recovery has introduced a novel, optimistic and healing tone into the field of mental health care. It is an energizing, user-driven movement pursuing evident- ly valuable goals. Probably, it does not need to prove its legitimacy by offering a coherent, comprehensive theoretical framework. If, however, recovery is con- ceptualized as a theoretical model that offers itself to scientific evaluation, we argue that the stigma perspective is essential to eliminate some of the blind spots of recovery.

In their model of recovery and self-efficacy, Bellack and Drapalski try to root recovery in established theoretical frameworks. Quite convincingly, they choose Bandura’s self-efficacy concept as a key element influencing the process of recovery, and they refer to stigma as an element contributing to those adverse personal experiences that reduce self-efficacy and thus hinder recovery. Using an individual perspective, their model thus accounts for the discouraging reality stigma creates for those with mental disorders. In fact, a lot of recent stigma research has focussed on the individual stigma experiences of persons with mental illness. Studies have examined different approaches to cope with stigma 2, highlighting the importance of individual, flexible strategies. Other studies have examined individual consequences of self-stigma and have found that internalization of common prejudices reduces morale and self-efficacy 3, or increases hospitalization 4. Here, stigma and recovery offer different perspectives on the individual experiences of persons with mental illness and, with their differing emphasis on resources and restraints, these perspectives complement each other.

However, the stigma perspective is not genuinely an individual one. Rooted as well in sociology as in social psychology, a lot of research on mental illness stigma has taken a societal perspective 5, trying to understand the cultural context that shapes individual experiences of those with mental illness and to describe discriminatory mechanisms that act to their disadvantage. From this societal perspective, theoretical models have been developed and tested, capable of predicting public attitudes and identifying target attitudes for change – because public attitudes do change 6. Another important societal aspect of stigma is structural discrimination, occurring when structures like legislation, rules, health insurance coverage etc. are set up in a way that puts members of a certain minority at a disadvantage 7. The rich theoretical work on stigma has enabled the exchange with other scientific discourses on discrimination, for example related to racism 8. Here, the individual perspective of recovery needs completion by the societal perspective offered by stigma research. Stigma is not primarily an issue of changing attitudes of the affected individual, but of changing public attitudes. Discrimination is not primarily a problem of individual coping, but of injustice.

Finally a word of caution seems warranted. The emphasis of the recovery movement on consumer control of their life may have unwanted consequences. It could increase public attributions of offset-responsibility for the condition to those afflicted 9, holding individuals responsible for the way they cope with their illness. By increasing blame, this could increase the stigma attached to mental illness instead of reducing it. Nowadays, in neoliberal times, there is also a certain risk that this “responsibilization” 10 of patients may in the long run result in reducing public spending on mental health services instead of helping improving their quality.

Research on recovery should be aware of these restrictions to the recovery perspective. Probably, research on recovery would benefit most from reassessing those models and findings that have been well established, for example in the field of stigma research, and utilize a multitude of perspectives to promote recovery. This would be an ambitious and worthwhile research agenda, and it would help to implement recovery as a natural element of mental illness and mental health care.