The stigmatization of mental illness has returned to the news with claims that President Trump has a mental illness and that this disqualifies him from serving. In response, the Bazelon Center has issued a statement that notes, “Having a mental health disability does not mean that a person is ‘bad,’ ‘dangerous,’ or ‘unhinged.’  And calling the President ‘mentally ill’ in order to insult or undermine him causes actual harm to people with mental health disabilities. The false assumption that a person with a mental health disability is unfit has caused many people to be denied jobs, lose housing, or have children removed from their custody, regardless of their capabilities as an employee, a tenant, or a parent.” The exchange is as polarized as public statements get these days; either mental health problems mean Typhoid Mary or they should be ignored in all fitness decisions. I hope to integrate perspectives by providing some clarity around stigma.

Stigma is an identity element—something the person is or has done—that disqualifies the individual from playing a particular role (Goffman, 1963). No matter how skilled a doctor she is, no American hospital is going to credit her as one if she hasn’t gone to medical school. The lack of an accredited diploma discredits her attempt to perform the role of doctor. No matter how trenchant the comment, no churchgoer is authorized to issue it during a silent moment of prayer, and the act will discredit the performance of churchgoer. Many people would endorse both these examples, and indeed the primary function of stigmatizing is to foster conformity in groups and structural clarity around roles. If you’re an atheist, you need some explanation of how we keep each other in line without referencing religious morality, and Goffman provides it.

Structural clarity means that people stay in their roles. All encounters go better when this is true, but it is hard to tell sometimes what is appropriate to do in a given role in a given encounter. Thus, moms should act like moms, but this can mean staying at home with the kids or providing an income. Waiters should act like waiters, but this can mean shuttling your food or participating in your dining experience. Unfortunately, stigma also operates in situations where its only purpose is to foster conformity and structural clarity, even when the conformity is dysfunctional or the structure is ill-advised. This happens because the general advantages of conformity and structural clarity become valued over the question of whether the particular agenda and structure are optimum. (We also stigmatize aspects of ourselves that don’t fit the identity we are fostering, but that is for a different post.)

Goffman provides the example of a blind man who was not authorized to crack jokes. He was warmly accepted at the local barber shop, but only in the stigmatizing role of a 'needy invalid.' When he cracked a joke, people would react as if he needed something. My own latest example is the people I encouraged to apply for a job who were only broadly qualified but lacked specific expertise in the subject. I told them all that they could pick up the expertise between submitting the application and getting an interview. The women did not apply and only one of the men did, but the other men didn’t apply for other reasons; the women felt unqualified. The role in question was substance abuse professor and the women felt that a lack of expertise was a stigma where the men did not. It’s entirely possible that both were correct, that the world would stigmatize a lack of expertise in the women and not in the men. Black people are stigmatized whenever they cannot play a role without the “black” label. In many situations, even friendly ones, the black person is not authorized to play the role of graduate student or coffeehouse patron or motorist; he or she can pull off only the roles of black graduate student, black diner, or black driver.

Not all stigmas are socially constructed. Manual palsy should disqualify a surgeon, pervasive emotional lability an air traffic controller, and senility a president or top-tier basketball coach. Every accurately labeled mental health problem, whether biologically or behaviorally based, implies some roles that the person cannot pull off: indeed, that is what is meant by psychopathology.

When we talk about the damage associated with stigmatizing psychopathology, we mean the discouragement from seeking effective treatments. Depression should be stigmatized in certain situations, because there are certain things that depressed people cannot do, certain roles they cannot play (or cannot play reliably). If that weren’t true, “depression” would have no meaning. But society not only discredits a depressed person’s ability to perform comfortably in situations that require a lot of energy or self-acceptance, it also shames him. And then it shames him for seeking help.

Stigmas tend to generalize; if someone is stigmatized in one role, stigma is likely in others. This is where the Bazelon Center has a point. People with disabilities (and disorders) are not unable to do everything, only some things. But the statement goes too far when it claims that all attributions of unfitness are false.

I may as well weigh in on my thoughts about President Trump. Virtually everyone experiences a decline in fluid intelligence after about 70 years on the planet. (During the election between two 70-year-olds, I said that I hoped that if terrorists attack, they do it in the morning, when either potential president would likely be sharpest.) An ensuing difficulty in making snap decisions is only tangentially related to being an effective president, at least as far as I can tell from observing the cognitively-compromised performance of Jed Bartlet on The West Wing. If narcissism were a bar to office, I doubt we’d have any politicians left, since running for office, underneath all the rhetoric about serving, pretty uniformly implies a sense of being something special. I doubt that anyone’s Twitter behavior is a good guide to functioning elsewhere, especially after a massive reinforcement (getting elected) for using Twitter to counterpunch against anything that smacks of insult. The same goes in my opinion for plain and offensive speech, the maintenance of which is more an indication of where America is than where the president is.

References

Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. New York: Simon and Schuster.

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