“The Painted Bird” is the tittle of a novel by a Polish-American writer, Jerzy Kosinski, and describes World War II as seen by a Jewish (or Gipsy?) boy wandering through small towns in Nazi-occupied Eastern Europe. At some point the boy is in the company of a professional bird catcher. He watches how the man took one of his captured birds and painted it several colors. The man then released the bird, which flew in search of a flock of its kin. But when the painted bird came upon the flock, they saw it as an intruder and viciously attacked it to death. The boy watches how the bird falls from the sky, killed by its own.
The title of the novel has already been borrowed for an article on mental health stigma published in the Psychiatric Times in 2013. The story about a bird being killed by its own because of being painted catches the essence of what stigma is indeed, so I choose to re-borrow the title for my post.
Stigma is a mark of shame and disgrace that sets a person apart.
The word “stigma” is of Greek origin and in the ancient times it referred to a scar made by a hot iron on the bodies of criminals to mark their infamy. The scar was a sign of discredit and danger, and a signal that a marked person didn’t deserve the same treatment as others. You can only imagine how it was like to go through a crowded street of an ancient Greek city with a mark “attention, here goes a criminal”, even if the mistake the person made was placed long back in time.
In modern times marks of shame and disgrace are no longer physical. They leave no trace on bodies, but their impact on human lives is equally powerful as in the ancient times.
People can be stigmatized because of any feature that makes them distinct from the majority. Stigmatizations occurs not by burning a mark on their bodies, but by attaching social prejudice to this feature.
In the field of mental health, the word stigma refers to prejudice, discrimination and negative social attitudes towards people suffering from mental health problems. The “mark” here is usually a psychiatric diagnosis. However, the fact of utilizing mental health services is sometimes enough to get marked, even if one lacks a formal diagnosis. Once set on an individual, the scar of mental illness may stigmatize a whole family or even friends. It’s like if the personal disgrace casts a shadow of shame on everybody around. In literature, it is called vicarious stigma. This kind of generalized stigma may bring about the loss of co-stigmatized friends and families, who get tired of bearing the burden of discredit. And when everybody has gone, loneliness knocks on the door. I have unfortunately heard many such stories.
Being a clinician, I view mental health stigma as one of the major obstacles for effective care and treatment. It’s a real enemy. It goes between me and my clients, making us unable to reach each other. Shame and fear of being discriminated prevent people from seeking help, even when they are unable to cope with their problems on their own. And if they decide to seek professional help, stigma often leads to discrimination of psychiatric patients within health care systems.
Stigma undermines social support, which is so important for recovery. It is a sad paradox, that because of prejudice people keep away from those who need them most.
I always discuss mental health stigma in my therapeutic groups and I regularly hear that for some of the patients, stigma is more disabling than symptoms themselves.
That’s only half of the story. Another half is that stigmatizing social attitudes can become internalized and can lead to self-stigmatization. Did you ever hear the saying: “A lie told often enough becomes the truth”? It’s about propaganda, and it’s about how sometimes our identities are created. We learn who we are by looking at ourselves through other people’s eyes and through the lenses of cultural “truths”. Any propaganda told to us about ourselves, even completely absurd, may become the “truth” if it is repeated often enough. This means that we can internalize stigmatizing attitudes and start seeing ourselves as someone of lesser worth.
Self-stigmatization makes people feel ashamed and guilty because of symptoms they neither have chosen nor can control. Self-devaluating propaganda effectively diminishes self-esteem and self-worth. Shame and feeling of inferiority make people withdraw form social contacts, although social support is then more important than whenever. And gradually, stigma may become an autonomous and even predominant factor perpetuating psychopathology.
There are a lot of publications discussing social processes that fuel and perpetuate mental health stigma. One of those processes is the way in which mass media present mental illness. This topic is outside the scope of my post, but you can easily google resources on the internet. There are also several articles linking stigma to different demographic variables, like age, sex, level of education, socioeconomic status etc. In this post, however, I would like to focus specifically on the cultural dimensions of stigmatization.
CULTURE AND STIGMA
As a clinician, trainer and supervisor who works across cultures I have a seldom privilege of witnessing how people looking at the same world through different windows can see a totally different reality. It applies both to clients and to clinicians – culture puts lenses on all of us. So, what does research say about cross-cultural differences in stigmatizing attitudes?
It is known that in some cultures people who suffer from mental health problems are more likely to be stigmatized than in other cultures. Research has, for example, shown that non-Caucasian UK migrants hold less favorable attitudes towards mentally ill people than Caucasians. (Bhugra, 1989)
A study conducted on the nationally representative samples of African Americans and Caucasian Americans showed that African Americans were more likely than Caucasians to believe that people suffering from schizophrenia or major depression would do something violent against other people. The difference between both groups remained significant even after controlling for age, political views, family income, education, and religion (Anglin et al. 2006)
Yes, cultures differ in the level of mental health stigma and the differences are sometimes very strong. This has been well researched and documented. But the key question remains: what causes those differences? In other words, which aspect of a culture is responsible for a higher or lower level of stigmatization? Why are people from one culture more prone to stigmatize others than people from another culture, even after controlling for a range of socio-demographic variables, like social status, religion or education?
An answer to these questions is important because – on the one hand – culture shapes our behaviors and attitudes, and – on the other – culture itself is shaped by us. So to some extent we can control what controls us and we can consciously choose to re-shape the culture in a way that supports our resilience instead of making us more vulnerable.
INDIVIDUALISM VS COLLECTIVISM
Cultures may be looked at from many angles, one of which is a collectivism-individualism dimension. In individualistic cultures, personal goals have primacy over group goals. Society is viewed as a platform for collaboration between individuals who pursue shared goals, interests and values. Individualism affirms uniqueness, self-determination and autonomy.
People are viewed as independent individuals responsible for their own lives and the choices they make. Collaboration is meaningful as long as it serves everybody, otherwise it is viewed as exploitation. This makes the level of within-group competitiveness to be higher than in collectivistic cultures. Individualistic societies do not pressurize individuals to fit into the group or to be “correct”. They expect that no one harms or restrains rights of other group members.
In collectivistic cultures, group goals have always primacy over individual goals. Collectivism values belonging, interdependence, and reliance on the group rather than on own abilities. Society has its own overarching goals and values, which are expected to be adopted and pursued by all members. Individual interests serve “greater good” and are dismissed if they may weaken the group. Thus, collaboration is a default quality of within-group interactions and competitiveness is perceived as a threat. In this type of culture, people don’t want to stand out from the crowd. The group serves not only as a protector and a source of support but also as a guide in choosing personal values and goals. Behaviors and attitudes are judged against how well they match group norms. Groups protect their overarching interests against individual ambitions by using a system of sanctions and by continuous surveillance. Individuals are discouraged from changing their social rank as it would serve only individual ambitions and not group interests. Group cohesion and harmony are core cultural values. In collectivistic societies, the level of conformity and “political correctness” is very high and is fueled by shame and fear of ostracism.
Western cultures are traditionally viewed as individualistic, while Eastern as collectivistic. But the demarcation line goes also across policies, with individualism being strongly promoted in anti-globalism – as opposed to collectivistic values of corporate socialism.
The individualism-collectivism dimension has recently attracted the attention of Western psychologists, some of whom directly promote a collectivistic transformation of Western societies and adoption of traditional Eastern social values. One of their arguments is that a lower level of within-group competitiveness makes the group stronger in between-group competition. But is it true? When we look at the history of mankind it doesn’t seem to be so. Competition is usually won by those who are technologically superior and, at least to me, it seems like a high level of individualism stimulates development of technology. This discussion, however, lies outside of my area of competence so I won’t go any further. You can find some readings and draw your own conclusions, if the topic interests you. Let us stick to the field of mental health in this blog.
I’ve always had doubts about benefits of collectivistic values for mental health because of the high rate of suicide reported in traditionally collectivistic societies.
Proponents of collectivism, argue it provides individuals with a higher level of social support. And here is the point where I disagree, too. Yes, the level of social support is higher for those who “fit in” (and so is the level of control). But what about those who do not fit in? What about the painted birds?
Tolerance for diversity and for deviation from standards is greater in individualistic than in collectivistic societies. Individualistic societies do not feel threatened by uniqueness, so the number of available cultural choices, lifestyles, and moral options is also higher. Those who are perceived as being “outside the norm” are not perceived as undermining the harmony of the group so the level of surveillance is also lower. The range of accepted behaviors is much broader and it is reasonable to expect that the level of stigmatization will also be lower.
The role of individualism-collectivism in mental health stigma was directly researched by Papadopoulos, Foster and Caldwell (2011). Results of their cross-sectional study conducted on 305 UK-based individuals of diverse cultural backgrounds suggests that: (1) the more stigmatizing a culture’s mental illness attitudes are, the more likely collectivism effectively explains these attitudes; (2) the more positive a culture’s mental illness attitudes, the more likely individualism effectively explains these attitudes.
It is worth mentioning that the negative, stigmatizing attitudes in collectivistic groups may be masked by what we call “political correctness”. It happens when those in charge of the group impose new norms and rules that are incompatible with the real attitudes of group members. Openness to diversity is then based on the pliancy with group norms, while personal attitudes get suppressed under the surface of overt behaviors. The suppressed attitudes have, however, a tendency to “leak out” in situation when people are not fully aware of their reactions. What is interesting, people with suppressed attitudes tend to avoid or even attack those who manifest the same attitudes overtly.
TAKE AWAY MESSAGE
When writing a blog, the author often has no idea who will be reading it. Neither have I. I just hope it will contribute to the awareness of stigma.
If it happens that you are the painted bird, whatever your paint may be, my message is: “Do not fear!” You don’t have to fit in to be able to fly. There are millions of other painted birds in the world and there are people out there ready to stand up for you. Just look around and try to find them.
As an experienced clinician, I have my personal dream: I see all painted birds spreading their wings one day and flying safely into the sky to surf on the wind of dignity. In case you are a clinician sharing my dream, forward this text to your colleagues and clients – if you think it is worth attention.
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.