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Conceptualizing Stigma and Barriers to Care 53
answer those questions and then form a scale that works pretty well in measuring
the perceived devaluation and discrimination against people with mental illness.
The main idea is that for people who never develop a mental illness, their function
is not related to their score on the perceived devaluation-discrimination scale.
But for people who develop a mental illness, the stronger their belief that people
reject others with mental illness, the worse they are likely to feel, to perform, to
withdraw and to have a constricted social network. This theory has been tested
with longitudinal data, and we have looked at effects on unemployment, income
loss, constricted social networks, quality of life, depressive symptoms, delayed help
seeking and self esteem.
As far as implications for help-seeking in military situations, it is possible to ask
these questions framed in terms of what soldiers or most military personnel think
about someone with mental illness. From the theory, we would expect that the
stronger the belief that others would look down or discriminate on someone with
mental illness, the less likely someone with a psychiatric problem would be to seek
help. What would we do if that theory were true Do you really want to tell people
that other people will not reject them One response is that the extreme fear is probably
excessive, and we could bring that down some. People do not have to fear at
the far end of this scale that everyone is going to vilify them. That is probably not
in accord with reality. We could change that belief some to good effect. The second
response is to change the ambient culture of beliefs, and if we can find ways to do
that, then we would be able to move forward and do some good.
The last major topic I want to talk about is motivations for stigma. We often
think about stigma as stemming from ignorance. There is a great deal of truth to
that perhaps, but people can get things they want from stigmatizing. One motivation
is exploitation. For example, racism was a way of justifying slavery. That is
an example of stigma in the service of exploitation. Another motivation is norm
enforcement, or keeping people in. Stigma can be useful for telling ourselves when we
step out of bounds, and we stigmatize people who step out of bounds to bring them
back in. The final motivation is disease avoidance, or keeping people away.
I think norm enforcement is particularly important for this forum. In military
settings, we need people to be strong. We need them to be brave. We need them to self
deny. To reinforce such norms, perceived weakness is stigmatized as a way of keeping
people in. From the vantage point that stigma serves a purpose, the question becomes
how do we serve that purpose without stigmatizing mental health help-seeking Can
we exempt psychiatric and psychological problems from being perceived as weakness
in these cultures A solution may be to convince people who need these norms
to be reinforced to keep those norms strong but to exempt psychiatric problems
from them.
To summarize, stigma is a multi‐faceted concept. Many concepts have to be integrated
to understand all the ways in which stigma expresses itself. Stigma-based barriers
involve multiple mechanisms of discrimination, not just person‐to‐person discrimination,
but also structural discrimination that operates through the individual.
Modified labeling theory suggests mechanisms that could produce barriers to treatment
seeking in military and other situations. Norm enforcement—keeping people
in—may be a motivation for stigma that is particularly strong in the military context.
DR. PESCOSOLIDO: I start with a confession. I am not a psychiatric epidemiologist.
In fact, I am not an epidemiologist of any sort. I belong to that group which
is much less revered, the group of health services researchers. I entered this area of
To summarize, stigma
is a multi‐faceted
concept. Many
concepts have to
be integrated to
understand all the
ways in which stigma
expresses itself.