Diagnosis and Stigma: reading notes on Patrick Corrigan “How Clinical Diagnosis Might Exacerbate the Stigma of Mental Illness

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Reading notes from: Corrigan, Patrick. (2007). How clinical diagnosis might exacerbate the stigma of mental illness. Social Work, 52 (1), 31-30.

Corrigan approaches the process of stigma and its relation to clinical diagnosis via cognitive behavioral theory. He presents the following template: Cue (e.g. an overt physical mark or a covert label) -> Stereotype (beliefs about all members of a marked group) -> Prejudice (stereotype is believed in a negative way) -> Discrimination (out- group is either coerced or avoided while the in-group receives favored help and association).

Corrigan defines stigma as, “a mark [cue] meant to publicly and prominently represent immoral status” (p. 32). Marks can be overt (e.g., skin color, obesity, etc.) or covert (gay, religious affiliation, diagnostic label, etc.). Stereotypes are defined as, “knowledge structures that are learned by most members of a cued-in social group” (p. 32). Stereotypes allow for easy and efficient categorization. One might know or be aware of a given stereotype, though they need not agree with the category or its description. Prejudice refers to persons who endorse stereotypes in negative ways (e.g., “That’s right, all mentally ill persons are violent”). Prejudice is usually cognitive, affective, or both, and leads to negative discrimination in the form of behavioral reactions toward the out-group (e.g., outright violence such as lynching, discriminatory policies such as Jim Crow, or avoidance such as not renting or employing persons who are gay, black, or carry a mental health diagnosis.

Corrigan says groupness, homogeneity, and stability each illustrate how diagnosis exacerbates stigma. Groupness is a group’s identity over and against another group. Group identity depends on identifiable differences (physical or label). It has been shown that groupness and stereotypes have a bidirectional causal relationship: without a marked group, there can be no stereotypes. Hence, diagnostic markers create groupness, which strengthens stereotypes (in this case, associated with mental illness). Less diagnostic markers entails less groupies, which means less stereotyping and discrimination. In- groups perceive out- groups as more homogenous than in-groups (e.g., all schizophrenics hallucinate). Diagnostic categorization reduces persons with real and significant differences to overgeneralized stereotypes. The result is a stigmatized group that overlooks individual differences, and Corrigan shows this to be the case in hiring practices, where employers won’t hire someone because they belong to a diagnostic group. Finally, stereotypes are usually stable categories, meaning that the identifiable traits are assumed to be static and unchanging. Thus, it is believed that persons with SPMI do not recover. This breeds pessimism in both groups. In- groupers don’t take chances on SPMI, and out-groupers don’t try to recover.

Diagnostic labels harm persons in three ways. First, because of the egregious effects of label stigma, many persons opt out of or do not pursue the treatment they need. Second, because they do not get the help they need, many experience blocked opportunities such as competitive employment, housing, general food and medical care. Prejudice toward persons with SPMI by employers, landlords, and doctors, exacerbates this. Third, persons with SPMI internalize these stigmas and believe they are worth less than others. Such beliefs fuel a devalued and shame based self, which yields behaviors that are counterproductive.

Corrigan suggests diagnosing on a dimensional continuum rather than categorically, emphasize the complexity of the individual rather than the group and interact with participants in recovery, not just when they are decompensated, and replace assumptions about poor prognosis with models of recovery.

Diagnostic labels are stigmatizing in that they function to create a normalized in-group and a mentally ill out-group. Out-group persons are classified as homogenous and static rather than as idiosyncratic and recovering. Dimensional diagnosis and focus on recovery challenge the process of stigmatization by blurring difference through continuums that include normalcy.

Questions:

1. Corrigan approaches diagnosis and stigma via CBT. Why? Might other theoretical approaches (e.g., psychoanalytic) yield different more productive results?

2. Corrigan argues that the mentally ill will be less stigmatized if diagnostic labels are suspended. And yet, Corrigan notes that stigma and groupness are ancient (p. 32). Some authors argue that stigma and groupies are constitutive of society as such (i.e., Girard, Lacan, Freud, et.al.). Does this problematize his thesis?

3. Corrigan privileges the ideographic- idiosyncratic individual vis a vis diagnostic grouping- categorization. Does this belie an American, capitalist ideology?

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