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Academic Psychiatry
ISSN 1042-9670
Acad Psychiatry
DOI 10.1007/s40596-015-0391-0
Managing Stigma Effectively: What Social
Psychology and Social Neuroscience Can
Teach Us
James L.Griffith & Brandon A.Kohrt
1 23
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COLUMN: EDUCATIONAL RESOURCE
Managing Stigma Effectively: What Social Psychology and Social
Neuroscience Can Teach Us
James L. Griffith
1
&Brandon A. Kohrt
2
Received: 14 January 2015 /Accepted: 18 June 2015
#Academic Psychiatry 2015
Abstract Psychiatric education is confronted with three bar-
riers to managing stigma associated with mental health treat-
ment. First, there are limited evidence-based practices for stig-
ma reduction, and interventions to deal with stigma against
mental health care providers are especially lacking. Second,
there is a scarcity of training models for mental health profes-
sionals on how to reduce stigma in clinical services. Third,
there is a lack of conceptual models for neuroscience ap-
proaches to stigma reduction, which are a requirement for
high-tier competency in the ACGME Milestones for Psychi-
atry. The George Washington University (GWU) psychiatry
residency program has developed an eight-week course on
managing stigma that is based on social psychology and social
neuroscience research. The course draws upon social neuro-
science research demonstrating that stigma is a normal func-
tion of normal brains resulting from evolutionary processes in
human group behavior. Based on these processes, stigma can
be categorized according to different threats that include peril
stigma, disruption stigma, empathy fatigue, moral stigma, and
courtesy stigma. Grounded in social neuroscience mecha-
nisms, residents are taught to develop interventions to manage
stigma. Case examples illustrate application to common clin-
ical challenges: (1) helping patients anticipate and manage
stigma encountered in the family, community, or workplace;
(2) ameliorating internalized stigma among patients; (3)
conducting effective treatment from a stigmatized position
due to prejudice from medical colleagues or patients' family
members; and (4) facilitating patient treatment plans when
stigma precludes engagement with mental health profes-
sionals. This curriculum addresses the need for educating
trainees to manage stigma in clinical settings. Future studies
are needed to evaluate changes in clinical practices and patient
outcomes as a result of social neuroscience-based training on
managing stigma.
Keywords Curriculum development .Residents .
Neurosciences
The Greeks, who were apparently strong on visual aids,
originated the term stigma to refer to bodily sins de-
signed to expose something unusual and bad about the
moral status of the signifier. The signs were cut or burnt
into the body and advertised that the bearer was a slave,
a criminal, or a traitor—a blemished person, ritually
polluted,tobeavoided,especiallyinpublicplaces.
“From Stigma by Erving Goffman ([1], p. 1)”
People diagnosed with mental illnesses are too often
viewed as incompetent, irresponsible, unpredictable, and dan-
gerous [2]. Psychiatrists are often viewed negatively by the
public and medical colleagues as odd, ineffectual, agents of
repression, abusive, or suffering from mental illnesses [3]. A
2009 Task Force of the World Psychiatric Association (WPA)
found stigma against psychiatry and psychiatrists to exist in
every society studied [3]. Professional psychiatric organiza-
tions repeatedly attempt campaigns against stigma as a center-
piece of health policy and advocacy. After examining 7296
publications worldwide, however, the WPA Task Force found
a scarcity of research on interventions that effectively combat
*James L. Griffith
jgriffith@mfa.gwu.edu
1
The George Washington University, Washington, DC, USA
2
Duke Global Health Institute, Duke University, Durham, NC, USA
Acad Psychiatry
DOI 10.1007/s40596-015-0391-0
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stigma, and no studies at all on interventions specifically
targeting stigmatization and discrimination of psychiatrists
[3]. Further, public campaigns and interventions to educate
the public about the neurobiological bases of mental illnesses
have limited benefits and may worsen stigmatization ofperson
with mental illness [4–6]. The term “stigma”itself has come
under scrutiny as too all-inclusive for a broad range of nega-
tive experiences associated with mental illness, thus limiting
elucidation of specific mechanisms and effective
interventions.
There are reasons for optimism, however. Recent decades
of social psychology research have identified fundamental and
distinct social processes that produce stereotyping, stigmati-
zation, prejudice, and discrimination [2]. Interventions that
facilitate face-to-face interactions between health workers
and persons in recovery from mental illnesses have shown
promise for reducing stigma [5]. Processes by which these
social exposure models work is supported by social neurosci-
ence research, which has elucidated neural circuitry of social
cognition that transforms detection of a mark of stigma into
specific aversive emotions and discriminatory behaviors [7].
This emerging understanding of social cognition at behavioral
and neural circuitry levels has opened new avenues for defin-
ing and combating stigma against psychiatry and mental ill-
nesses. We suggest that
&Social neuroscience research can display step-wise, se-
quential processing of social information within brain cir-
cuitry and signaling pathways;
&Stigma assessment based upon social psychology and so-
cial neuroscience can identify types of stigma with strate-
gies best fitted for countering that type;
&Social psychology research has begun empirically validat-
ing effective interventions for neutralizing stigma and
prejudice. However, these evidence-based interventions
have not yet been broadly disseminated within psychiatric
training and clinical practices. A clinical model for stigma
management based upon social psychology and social
neuroscience research can help remedy this shortfall if
taught during psychiatry residencies.
The George Washington University (GWU) psychiatry res-
idency has developed a curriculum for training psychiatry
residents to assess, formulate, and implement interventions
to attenuate stigma. This is in keeping with the Accreditation
Council on Graduate Medical Education (ACGME) and
American Board of Psychiatry and Neurology (ABPN) Mile-
stone Project, which identifies integration of knowledge of
neurobiology into advocacy for psychiatric patient care and
stigma reduction (Milestone 5.4/D) as a high-tier competency
[8]. The GWU curriculum is informed by social psychology
and social neuroscience research [9–11]. In this paper, we
present the conceptual background for understanding stigma
from a social psychology and social neuroscience perspective.
Then, we summarize educational modules with associated
case illustrations for teaching residents.
This innovative curriculum addresses three gaps in aca-
demic psychiatry: the lack of interventions for stigma reduc-
tion in psychiatric care; the lack of training techniques on
stigma reduction for trainees; and the lack of models for stig-
ma reduction that incorporate neuroscience in accord with
ACGME/ABPN Milestones [8].
Stigma—An Affliction of Normal People and Normal
Brains
Stigma is “the situation of the individual who is disqualified
from full social acceptance”([1], preface) due to “the dynam-
ics of shameful differentness”([1], p. 140). Stigma is a social
construction that involves two fundamental components: the
recognition of difference based on some distinguishing char-
acteristic—a“mark,”and a consequent devaluation of that
person [1,12]. Stigma can arise from membership in a group,
such as “the mentally ill”or “psychiatrists,”who are devalued
in particular social contexts [13]. Stigmatized individuals are
regarded as flawed, compromised, and somehow less than
fully human, identifiable by the presence of their mark. Stig-
ma can rob a person with a mental illness of much that makes
life worth living.
Goffman’s original ethnographic descriptions of how stig-
ma processes occur have been updated through understand-
ings from evolutionary psychology about why stigmatization
occurs. Evolutionary psychology suggests that stigma is a
byproduct of normal group behavior [14]. Hominid evolution
was associated with increasing capacities for organizing tight-
ly cohesive, organized groups. These capacities manifest as
leadership and followership, hierarchy, roles and responsibil-
ities, boundaries, and reciprocal altruism within groups. The
capacity to detect group members who were deemed too dif-
ferent or who risked impeding the group’s functioning became
the human capacity to stigmatize.
From an evolutionary perspective, stigma is cognitively
efficient: stigma results from cognitive heuristics and biases
that make reflective thought unnecessary for rapid social judg-
ments [15]. Functional brain imaging has clarified how these
evolutionary processes of social cognition derive from dual
systems: one for rapid, categorical, group member-to-group
member relatedness and another for slower, individualized,
person-to-person relatedness. Categorical social cognition
functions as a threat detection and management system that
ensures security of the group. Categorical social cognition
relies upon sociobiological systems that act as sensors,
conducting surveillance over social space. These include so-
ciobiological systems for social hierarchy, peer affiliation (in-
group social bonds), social exchange (in-group reciprocal
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altruism), and kin recognition (distinguishing in-group from
out-group members) ([16], pp. 13-55). Each system appears to
have distinct circuitry elements [17].
Types of stigma reflect different survival concerns for
the reference group and are reflected in different methods
for social surveillance. These different methods require
specific counter-tactics to disrupt their operations. Stigma
types particularly relevant for persons with mental illnesses
include the following:
(1) Peril stigma triggers perceptions of potential danger,
such as a person with a mental illness who shows odd,
impulsive, or unpredictable behaviors;
(2) Moral stigma is stigma in which a person is perceived as
a threat for challenging the group’s beliefs and values.
Symptoms of mental illness, such as a patient’snegative
symptoms of psychosis, behavioral avoidance of anxiety
disorders, or apathy of depression, may trigger moral
stigma when interpreted as laziness, unwillingness to
accept personal responsibility for one’s life, or lack of
predictable conformity to social rules of engagement.
(3) Disruption stigma occurs when a person’sbehaviorsor
symptoms are experienced as interfering with function-
ing of the family or work group. Interaction with persons
living with physical disabilities may invoke disruption
stigma because of concern that professional and social
obligations will be threatened by tending to that person’s
needs. Within healthcare systems, clinicians engage in
disruption stigma when psychiatric patients are not given
equal diagnostic vigilance or when they are “dumped”
onto other services.
(4) Empathy fatigue represents a form of stigma when
family members, friends, and co-workers feel too
distressed to engage in close proximity with per-
sons in suffering, i.e., a feeling that it is “too much
emotional work.”The result is avoidance or high
levels of social distance. Mental illnesses associated
with feelings of severe depression, anxiety, and
chronic pain may evoke empathy fatigue.
(5) Courtesy stigma is stigma by association that results in
loss of social status with physical proximity to a stig-
matized person, as if acquiring “courtesy member-
ship”in the stigmatized group [1]. Family members
or mental health professionals are vulnerable to cour-
tesy stigma by virtue of association with persons with
mental illness.
The most difficult of all stigmatizing processes to coun-
ter is perhaps internalized stigma. Internalized stigma re-
sults when stigma of whatever specific type becomes a
lens for self-perception that is judgmental, contemptuous,
and dismissive [4]. Patients feel disgust for their identity
as psychiatrically ill. Compassion for self is difficult to
muster. Loss of self-esteem, a sense of alienation, social
withdrawal, and self-hatred are common sequelae.
During categorical social cognition, the sociobiological
systems stream information about the social world through
the rostral anterior cingulate gyrus where it can be compared
to a model of expectable reality that has been constructed by
the prefrontal cortex from memory retrieval [18]. Detecting a
mark of stigma in a person’s environment appears to generate
conflict between incoming sociobiological information and an
expectable reality. When the anterior cingulate gyrus detects
this conflict, a need for additional control is signaled to the
prefrontal cortex. The dorsolateral and ventrolateral prefrontal
cortices then resolve the conflict by exercising top-down mod-
ulation over subcortical systems that constitute the pain ma-
trix, including the amygdala (fear), insula (disgust), and ven-
tral anterior cingulate gyrus (suffering) [17–19]. Activation of
the pain matrix produces proximate motivation for avoiding or
extruding the bearer of the stigmatizing mark. The flow of
mirror neuron information is then suppressed, and person-to-
person social cognition fails to activate. Empathy for the stig-
matized person is suspended. The stigmatized person is then
behaviorally extruded and oppressed, for which the
stigmatizer typically feels no guilt ([16], pp. 36-55).
Different types of stigma can recruit different brain circuits
and signaling pathways. Moral stigma, for examples, activates
circuitry of ventromedial prefrontal cortex that is essential for
generating social disgust [20]. Patients with damage to the
ventromedial prefrontal cortex lose their aversion to intimate
contact with strangers, social deviants, or those bearing mis-
fortunes, such as the poor or homeless, whereas their moral
disgust remained intact for those who violated the dignity of
others, as with unfairness, cheating, or betrayal [20].
Designing Interventions to Counter Stigma
The goal in stigma management is to move from these
categorical processes to person-to-person relatedness,
which is organized out of the mirror neuron system and
medial prefrontal systems for mentalization and empathy.
These “slow”systems from a cognitive processing per-
spective permit a highly individualized appraisal of anoth-
er person that includes emotional attunement ([16], pp. 13-
55). Decety and colleagues [21] suggest that some aspects
of physician training and experience may reduce mirror-
neuron mediated empathy. This suggestion was based on
their finding that non-medical participants showed differ-
ent patterns of event-related brain potentials (ERP) when
witnessing people experiencing painful vs. non-painful
stimuli, whereas internal medicine physicians showed no
ERP differences when watching persons experiencing
painful vs. non-painful stimuli. Reciprocal inhibition be-
tween person-to-person social cognition and categorical
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social cognition, which would potentially reestablish
some aspects of empathy, provides a major strategy for
countering interpersonal stigma. When a personal rela-
tionship can be established with another individual, cate-
gorical perception of that individual predictably fades
from attention. These pathways likely underlie the effec-
tiveness of social contact/exposure anti-stigma interven-
tions that facilitate interaction between potential
stigmatizers and persons with mental illness in recovery
[5]. Establishing person-to-person relatedness with a po-
tential stigmatizer as quickly as possible is thus a high
priority for a person at risk for stigmatization.
A second strategy has its underpinnings in the relationship
between high arousal states and a bias towards categorical
social cognition. Activation of the anterior cingulate gyrus
by perception of a stigmatizing mark not only activates the
prefrontal cortex but also the ventrolateral tegmentum (dopa-
minergic pathways) and locus coeruleus (noradrenergic path-
ways). These monoamine systems ascend to cortical and lim-
bic regions where their modulation heightens brain arousal,
primes the orienting reflex, and re-allocates attention for sen-
sitized detection of marks of stigma [18]. Arousal due to
threat, ambiguity, or uncertainty thus produces a shift towards
categorical social cognition. Conversely, a lowering of arousal
produces a shift towards person-to-person social cognition.
Lowering arousal can be achieved by minimizing perception
of threat, reducing ambiguity, and bolstering a sense of coher-
ence and predictability about the potential stigmatizer’s
circumstances.
Activating person-to-person social cognition, while
diminishing alertness to threat, together form the bedrock for
building strategies to counter stigma in interpersonal interac-
tions that psychiatrists face in clinical practice.
GWU Residency Seminar on Social Psychology
and Social Neuroscience of Stigma
Our George Washington University (GWU) psychiatry resi-
dency has created a didactic curriculum that teaches both a
scientific knowledgebase for understanding stigma against
mental illness and skill-sets for assessing, formulating, and
intervening to attenuate stigma. This seminar teaches residents
how to manage five types of clinical encounters in which
psychiatrists commonly confront stigma.
The 8-week combined postgraduate year-III (PGY-III) and
PGY-IV seminar integrates the study of social psychology and
social neuroscience research literature with experiential exer-
cises and clinical portfolios of assessment, formulation, and
anti-stigma interventions conducted within residents’clinical
settings. A full description of this seminar with learning ob-
jectives, readings, exercises, and methods of assessment are
available from the authors. Below is a brief summary of the
seminar modules.
Module I: Social Psychology and Social Neuroscience
of Stigma
Readings from social psychology and social neuroscience lit-
eratures teach distinctions between social processes of
stereotyping, stigma, prejudice, and discrimination, as well
as the clinical use of relevant psychological constructs, such
as social identity, identity flags, in-groups/out-groups, and
group entitativity. Entitativity refers to an in-group’slevelof
organization, or “groupiness,”which primes a readiness to
stigmatize out-group members. Experiential exercises help
residents to apply these constructs to their personal experi-
ences of stigmatization over the course of their lives.
As a group exercise, residents design a hypothetical new
stigma by treating as a mark of stigma a selected behavior that
might occur within the daily work lives of psychiatry resi-
dents. To illustrate this point, we have provided an excerpt
from a resident exercise generating a credible stigma utilizing
the following four-step “Stigma Generation Exercise”:
(1) Think of a behavior that a psychiatry resident could dis-
play that plausibly would become stigmatized because it
would disrupt the smooth and efficient functioning of
residents working together as a group. As a representa-
tive behavior, the residents identified introduction of new
clinical material for discussion just as end of day sign-out
rounds were concluding. Hand-off of patient care to the
night call team would then be unnecessarily lengthened
by the poor organization and lack of thoughtfulness of
the offending resident.
(2) What might constitute an identity flag that would enable
the rapid recognition of a resident showing this
behavior? “Looking through papers”—as the sign-out
discussion were ending, the offending resident would
begin rummaging through notes from which to re-open
discussion.
(3) Think of ways that you could think about, talk about, and
interact differently with that person so as to convey ef-
fectively that a resident with this mark of stigma is
discredited as a person and now holds lower status with-
in the whole group of residents. Other residents would
“roll eyes”or look away when the offending residents
would begin speaking and impatiently would interrupt
comments. This could progress to omitting the resident
from significant clinical conversations among residents.
(4) Think of ways that this stigmatized resident could be
discriminated against so that the espirit de corps of the
larger group of residents would be lifted or the larger
group would function more efficiently and effectively.
Over time, invitations to resident social activities, such
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as “happy hours,”would cease for the offending resident.
The resident also would be given “last picks”on
switches among residents for weekend or holiday calls.
Residents who participated in the stigma generation exer-
cise were surprised how quickly a credible stigma could be
generated (less than 10 min), the intensity of emotion it
evoked, and their lack of felt empathy towards the stigmatized
resident. The exercise helped make the point that stigma is a
social phenomena of normal people, not an indicator for men-
tal illness.
Module II: Helping Patients to Anticipate and Manage
Stigma in Family, Community, or Work Place Settings
Residents learn how to assess, formulate, and design anti-
stigma strategies by discerning first the stigmatizer’sgroup
of identity. A person who stigmatizes someone acts primar-
ily as a group member whose group of identity has been
threatened. Moral stigma, disruption stigma, and courtesy
stigma all share in common a sense of threat to the group of
identity. Each group conducts defensive surveillance of its
social space and does so uniquely depending upon what is
perceived as vital to its interests. A strategy to counter stig-
ma begins by appraising the methods a particular group
uses to monitor threats to its security. The following four-
step assessment prepares the groundwork for an anti-stigma
strategy (see Fig. 1, box A).
For designing interventions, residents study strategies that
have been honed across the ages by individuals stigmatized
for their ethnicity, religious beliefs, social class, or other social
identity. Applications of these strategies have been validated
in empirical social psychology research studies [2]. Figure 1
(box B) includes some of these strategies.
As an exercise, residents practice this assessment pro-
cess by appraising a psychiatric patient’s risks for stigma,
then tailoring an intervention that would anticipate and re-
duce the risk. This exercise was particularly suitable for
inpatients approaching discharge back to home, communi-
ty, and workplace.
Illustration: Ms. P. was a middle-aged woman admitted
briefly to a psychiatric inpatient unit for depression. Conver-
sations with Ms. P. revealed her impending reunion with her
family and her return to her workplace to be potential concerns
for stigmatization. However, the types of stigma differed. In
her family, moral stigma was expressed, more by her siblings
who viewed her depression as “weakness,”than by her hus-
band and children. An identity flag in her family was “never
asking for help,”and her babysitting requests when she felt
overwhelmed had been treated as marks of stigma. At work,
disruption stigma was the issue due to concerns that she might
not be able to maintain reliable productivity. An identity flag
in her office was “staying late until the job is done.”Leaving
early from her workday or visits to her psychiatrist had been
treated as marks of stigma. The psychiatry resident used role
plays to practice with Ms. P. “what to say to whom”about her
hospitalization, a plan to manage performance monitoring at
work, and engaging her husband’s help in managing her sib-
lings expectations.
Module III: Helping Patients Resolve Internalized Stigma
and Its Sequelae
Residents study research literature on internalized stigma with
its adverse impacts upon morale, relational lives, and treat-
ment adherence for psychiatric patients. Role plays are used
to practice psychotherapeutic strategies for recovery from in-
ternalized stigma by discovering aspects of oneself that are
unsullied, intact, and worthy, while mobilizing defiance of
the stigmatizing inner gaze. In manageable steps, patients
practice steps of recovery (see Fig. 1, box C).
Illustration: Mr. D. was mired in social isolation and self-
disgust for his disability status from a recurrent mood disorder.
Over the course of a brief psychotherapy, his psychiatry resi-
dent therapist focused detailed attention to the delicate care-
taking he had provided for his orchids that were of remarkable
beauty. Over the course of therapy, he slowly became able to
experience this caretaking as a core sense of his identity, and,
in time, to transfer the same care-taking to his personal well-
being, with heightened self-regard and new relationships with
others.
Module IV: Conducting Treatment Effectively
Despite Active Stigmatization by Medical Colleagues
When residents feel stigmatized by a patient, patient’sfamily,
or colleague, the residents’attention focus upon the stigma-
tizing person’s group of identity, not the patient, family mem-
ber, or colleague as an individual. The four-step assessment
(module II) is conducted to determine type(s) of stigma and
how that group’s social surveillance is conducted. Based upon
this assessment, a strategy is designed and implemented to
counter stigma against the mental health professional (see
Fig. 1,boxD).
Illustration: As a group, the PGY-III residency class felt
most stigmatized, not by patients, but by medical col-
leagues such as by Emergency Medicine attendings who
“hated psychiatry patients.”However, examination of
multiple vignettes revealed two unexpected conclusions.
First, peril stigma was an issue for some attendings who
feared the unpredictable violence that occasionally oc-
curred with psychotic patients. Second, both moral and
disruption stigma emerged from hospital rules that Emer-
gency Department attendings held authority to determine
admissions for the medical and surgical services, but psy-
chiatric admission decisions were made by the psychiatry
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resident. Emergency Medicine attendings were reacting
both to a slow-down in speed for transferring patients out
of the Emergency Department to the psychiatric unit by
needing to consult first a psychiatry resident. They also
reacted resentfully to what felt like a violation of hierarchy
for an attending to ask permission from a resident. The
PGY-III class brainstormed different strategies for on-
call residents to structure differently how they interacted
with Emergency Department attendings to minimize each
of these stigma pathways.
Module V: Conducting Treatment Effectively
Despite Active Stigmatization by Patients or Their
Families—Helping Patients Access Care from Lay,
Religious, or Other Healers When Professional Mental
Health Treatment Risks Shunning or Extrusion
by the Patient’s Group of Identity
Residents practice a four-step stigma assessment for pa-
tients or family members who stigmatize psychiatry.
Case discussions examine how residents have
implemented strategies for the stigmatized psychiatrist
in clinical encounters where they have been stigmatized
(see Fig. 1, box E). Key aspects of this process include
showing empathy for the patient’s predicament, includ-
ing the patient’s conflict from feeling coerced into meet-
ing with a psychiatrist; expressing “negative goodness”
by showing respect for the stigmatizing person’s group of
identity and by acknowledging and respecting differ-
ences; creating a climate of safety by minimizing percep-
tions of threat; and meeting the stigmatizing person as a
person, not as a category, by learning about the stigma-
tizing individual as a complex person possessing unique
ideas, emotions, and actions. The following vignette il-
lustrates how clinical work can be conducted effectively
from a stigmatized position, including efforts to help the
patient to find resources within his group of identity
([16], pp. 144-147):
Mr. B. was a young man for whom psychiatric consulta-
tion had been requested due to jerking movements diag-
nosed as psychogenic movement disorder by the consulting
neurologist. As the psychiatric consultant entered the room,
1. Identify stigmatizer’s group of identify. What group is a home for the values that the stigma is perceived to threaten?
2. Discern how this group conducts surveillance of its social space. Which sociobiological systems are most involved? What are “identity flags” to
which the group alerts?
3. Appraise how this group operates so that its stigmatization makes sense. What does the group perceive to be at stake? Is this a high entitativity or
low entitativity group?
4. Utilize these findings to design and implement an intervention that targets and defuses the stigmatizing process. The intervention should address
the kind of stigma and type of social surveillance involved. High entitativity groups require smaller, gentler steps and greater attention to courtesy,
and respectful acknowledgements of the other’s group of identity.
B Helping patients to anticipate and manage stigma in family,
community, or work place settings (Module II)
1. Discuss process, benefits, and drawbacks of learning to “pass” or
to “cover” so that the stigmatizing mark is unseen or little noticed
2. Develop patient’s abilities to assuage group concerns about threat;
3. Establishing a positive identity as a valuable group member
4. Establishing person-to-person relationships quickly with group
members before stigmatizing processes can be activated
5. Building strategic alliances and coalitions with other group
members
6. Pursuing overarching goals that bring stigmatized and non-
stigmatized individuals into positive face-to-face contact under a
broader umbrella
C Helping patients resolve internalized stigma and its sequelae
(Module III)
1. Deconstructing the stigma by identifying the reference group from
which it originated and examining motivations of that group for
promoting its values, judgments, and social categorization
2. Challenging practices of self-silencing and self-negation by
speaking in an unedited voice from authentic experience
3. Reaching out in solidarity with others who have also suffered
stigmatization
4. Utilizing personal spirituality to support a sense of personal
worthiness and beauty
5. Embracing one’s worthiness as a moral claim for justice
D Conducting treatment effectively despite active stigmatization by
medical colleagues (Module IV)
1. Identify instances where patient care may be compromised as a
result of medical colleagues attitudes toward mental health care
2. Determine type of stigma related to work role of medical colleagues
(e.g., exposure to violence/peril, perceived disruption of work-flow)
3. Develop person-to-person relation with medical colleagues to
counter categorical perception only as mental health worker
4. Collaboratively develop strategies to address specific type(s) of
stigma that impact medical colleagues identity
5. Facilitate person-to-person interactions between medical colleagues
and patients with mental health problems
E Conducting treatment effectively despite active stigmatization by
patients, families, and communities (Module V)
1. With patient, modulate emotional closeness and distance to find a
position “close enough to talk, but not so close as to threaten.”
2. Follow patient’s body to guide what can be said safely with words;
nonverbal response to threat indicates need to slow down, ask less
intrusive questions, and shorten interview;
3. Keep the horizons of the interview within a patient’s first-person
account of his or her experience; avoid diagnostic terminology;
4. Show empathy for the patient’s predicament, including his conflict
from feeling coerced into meeting with a psychiatrist;
5. Express “negative goodness” by showing respect for the stigmatizing
person’s group and by acknowledging and respecting differences;
6. Manage countertransference by fostering interest and curiosity about
the stigmatizing individual as a person.
A Four-Step Assessment of Stigma Process
Fig. 1 Four-step assessment of stigma and application to common challenges in clinical settings
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he sat up vigilantly in his bed, with a hostile demeanor and
minimal politeness.
The psychiatric consultant realized that Mr. B. felt humili-
ated by the presence of a psychiatrist in his care, which was
further evident in his vigorous denial of any current life
stressors or past psychiatric symptoms or treatment. Mr. B.
had struggled with severe diabetes since childhood.
The consultant inquired about Mr. B’s own theory as to the
origins and meaning of his medically unexplained symptoms.
Mr. B. responded angrily, telling how his internist had
confronted him with an abrupt accusation “there is nothing
wrong with you,”after medical tests reported normal findings.
Mr. B. felt stunned, betrayed, and bitterly angry. He fired the
doctor but then felt lost and confused where to turn next. He
eventually found his way to the GWU Neurology Department.
The consultant observed how Mr. B.’swarinesswas
diminishing as he spoke from his personal experience. The
consultant expressed empathy for B.’s frustration with his
medical caregivers, then asked an existential question to draw
Mr. B.’s motivations, values, and commitments into the dis-
cussion: “You are shouldering a lot—diabetes is a chronic
disease that requires more and more care as one grows older,
and it must take a lot of work to manage this plus the episodes
of jerking, and especially so since the doctors to whom you
have turned had been of no help. What has kept you from
giving up or being overwhelmed by all this?”
Mr. B. described how he attempted to utilize his religious
faith, including counseling from a religious professional, to
cope with problems in his life. He had attempted “to beat his
body into submission.”The psychiatric consultant kept his
formulation of the problem within Mr. B.’s religious
discourse:
“Perhaps you are locked in spiritual warfare between your
desire to live a life of the spirit and the desires of the flesh. The
tension produced might be making your body ill…There
might be other possibilities beside beating the flesh into sub-
mission or letting the flesh take over…I am concerned that as
you have tried to exert tighter and tighter control over your
feelings, the struggle and tension has increased, not lessened,
and it is making your body ill.”
While this formulation might have provided a reasonable
rationale for referring Mr. B. for psychotherapy, the psychiat-
ric consultant also realized that Mr. B.’s conservative religious
community would likely shun him were he to go outside the
religious community for help. He sought instead to organize a
recommendation within resources of Mr. B.’s religious in-
group: “If this idea has any merit, then I would recommend
that you work withsomeone who can understand what you are
struggling with, not try to do it alone. Psychotherapy with a
mental health professional who understands and respects your
faith could be one option. Perhaps seeing a pastoral counselor
who understands how a spiritual struggle might make the
body ill could be another possibility. I’ll bet you know
Christians who do not have this kind of warfare going on
within them. If you were to spend time with someone who is
older and has lived a lot of years, there might be things you
could learn.”Whereas treatment by a psychiatrist or psychol-
ogist would be unacceptable within his group, a psychologi-
cally mature elder in his church might be better positioned for
this role than a mental health professional.
Seminar Outcome Assessment
The seminar began as part of a programmatic effort to ground
the GW psychiatry residency in neuroscience research [9]. In its
first 4 years from 2009–2012, it was taught at the PGY-III level,
utilizing readings and handouts to teach clinical concepts of
stigma together with brain circuitry for dual social cognition
systems, in similar manner to the current manuscript. However,
seminar outcome assessments found that residents had gained
significant cognitive knowledge about stigma but were failing
to translate it into practical interventions in clinical encounters
[10]. The seminar was retired for a year and re-drafted to trans-
late knowledge about stigma into teachable practices.
The current 2014 seminar was taught with 11 PGY-III and
PGY-IV residents in a combined group. Residents in this
group were all US medical school educated but highly diverse
in terms of gender, ethnicity, race, religious identity, and sex-
ual identity. A draft of the current manuscript was utilized as a
core text so that residents’evaluation of the seminar could also
serve as a direct evaluation of the teaching model. Readings
were completed outside of class, and lecture time for each
session was limited to a 15-min review of key principles.
The remaining 75 min of each session were fully spent with
small group skill-building exercises that practiced stigma as-
sessment, formulation, and intervention for different types of
stigma in different contexts, employing role plays and enact-
ments drawn from encounters with stigma in residents’per-
sonal lives, GWU Hospital psychiatric services, or outpatient
community clinics.
The educational impact of the 2014 seminar was assessed
utilizing multiple methods that included the following:
A. In-Session Observed Assessments of Cognitive Learn-
ing—Reviews of core concepts and key ideas were con-
ducted weekly with the full group. For example, residents
were queried in group discussions: (1) to define stigma
and its key attributes, (2) to explain how stigma is gener-
ated via categorical social cognition, (3) to describe the
four steps for stigma assessment, formulation, and inter-
vention, and (4) to describe multiple types of intervention
strategies.
B. In-Session Observed Assessments of Procedural Learn-
ing—Small group memberships were changed weekly.
Each group performed four-step stigma assessment,
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formulation, and intervention exercises utilizing different
case examples in role played enactments until accrual of a
level of competency was observed.
C. Post-Seminar Assessment of Learning by Individuals—
An end of seminar assessment provided confidential
feedback from individual residents.
&Global rating for educational effectiveness of seminar
was 8.0 (range 6.0–9.0) on a zero-to-ten Likert scale;
&Nearly 50 % of respondents posted positive narrative
comments on use of role plays and enactments as
training tools;
&Comments for improvements included additional
readings, greater structure, and additional sessions
per module;
&One respondent requested 10-min decompression
time at the end of each session to process difficult
emotions that arose during the exercises.
D. Post-Seminar Assessment of Learning with Focus
Group—A focus group of all residents was used to iden-
tify strengths, accomplishments, and challenges.
&What was any useful new learning that you gained
from the seminar? First, learning that stigma against
mental illness can exist in multiple different catego-
ries, such as peril stigma, moral stigma, or disruption
stigma; second, gaining confidence that one can pos-
sess tools for managing stigma effectively; third,
learning the effectiveness of person-to-person contact
in attenuating stigma; and fourth, learning to describe
different steps in social cognition that underlie stigma,
which provides a way to talk about stigma in clinical
discussions.
&In what settings have you employed this new
learning? Two outpatient community mental health
center training sites were named where residents were
making efforts specifically to address internalized
stigma among patients with chronic psychiatric ill-
nesses. A resident commented that the seminar let
her to become more aware of how she might be per-
ceived by her patients in terms of social categoriza-
tion. Another commented that the seminar “helped me
figure out when I was stigmatizing.”
&Have there been problems or challenges with stigma
for which the seminar did not provide sufficient help?
The main challenge identified was how to help a pa-
tient stigmatized by family members when the family
took no role in the patient’streatment.
&What was your experience of participating in the role
plays, enactments, and discussions involving stigma
and prejudice? Here, residents’responses reflected
ambivalence. The exercise experiences brought home
the power of group identity and categorical social
cognition and the emotional impact of stigmatization.
One resident commented, “It can be good to remem-
ber. You draw closer to people in your group and try
to prove the others wrong.”However, another resi-
dent said, “It is hard to think about and talk about
how I’ve been stigmatized. It doesn’tdrawmecloser
to others,”and another responded, “Learning how to
intervene is good, but it brings up a lot of anger that I
have to do it.”Several residents told how the exercises
that focused on group identity also made them more
aware of group identities among the residents, which
created a sense of separateness.
In summary, the in-session assessments of learning con-
firmed by observation the learning of critical cognitive infor-
mation, as well as procedural learning for stigma management
in varied enactments and role plays. The post-seminar focus
group assessment demonstrated specific clinical sites and set-
tings where residents were implementing learning in practice,
with residents’reporting specific clinical successes in terms of
the following: (1) possessing specific tools with which to
counter stigma effectively, which empowered residents’sense
of effectiveness; (2) enabling residents to conduct successfully
some difficult clinical encounters that stigma might otherwise
have compromised; (3) providing language for describing and
discussing stigma as a difficult social process, i.e., “making
explicit the implicit”in an inpatient rounds discussion of a
case where stigma was impacting patient care; and (4) height-
ening self-awareness of one’s participation in stigmatizing
processes, e.g.,. “helped me figure out when I was stigmatiz-
ing.”It is important to note that experiences of participating in
training exercises that evoked past personal experiences of
stigmatization were felt both to be valuable and emotionally
distressing.
Conclusion
Stigma against psychiatry, psychiatrists, and individuals bear-
ing mental illnesses is universal among human societies. So-
cial psychology and social neuroscience can provide an un-
derstanding of stigma that yields more effective methods for
assessing, formulating, and implementing interventions for
countering stigma. This social psychology and social neuro-
science perspective helps identify steps in stigma generation
where targeted interventions are most likely to be effective. It
distinguishes multiple kinds of stigmatizing processes so that
interventions can be more specifically tailored. It also helps set
more realistic expectations for what can be accomplished with
programs of education, which have limited effectiveness with
implicit cognitive processes of interpersonal stigma, but great-
er effectiveness with explicit cognitive processes of
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institutionalized stigma and discrimination. It is teachable in a
residency seminar that blends didactic study with experiential
and group-learning exercises. This approach to breaking down
stigma into different types of threats and employing social
psychology may also benefit public campaigns to reduce stig-
ma against mental illness. To date, public campaigns that use
neuroscience to explain the etiology of mental illness have
limited and even exacerbating effects on stigma [6]. Instead,
social neuroscience theory could be employed with the public
as we have done with residents. There is preliminary support
for this as evidenced by positive outcomes for an anti-stigma
module employing these same principles which we included
in a mental health training for police officers in Liberia [22].
Future efforts for neuroscience-based training in reducing and
managing stigma should evaluate the impact of these curricula
on trainee behaviors, clinical practices, and patient outcomes.
Implications for Educators
•Residents need skills sets for countering stigma during
interpersonal encounters with stigmatizing patients, families, and
medical colleagues.
•Curricula are needed to prepare residents to integrate knowledge of
neurobiology to reduce stigma, which is a highest tier competency
(level 5) for Clinical Neuroscience (milestone 3) in the ACGME
Milestones for Psychiatry.
•Mental health trainees can be taught to improve managing stigma
by categorizing stigma according to peril threats, disruption threats,
empathy fatigue, and moral threats.
•Effective stigma management strategies incorporate reducing
arousal to threat and shifting interpersonal interactions from
categorical social cognition to person-to-person social cognition.
•Social neuroscience and social psychology research can be used to
understand stigma within the healthcare system and to manage
stigma against mental health clinicians from medical colleagues.
•Further research is needed to evaluate the impact of social
neuroscience-based stigma reduction on clinical practices and pa-
tient outcomes.
Acknowledgments The second author (BAK) has received funding
support through NIMH U19 MH095687 and NIMH K01 MH104310.
Disclosures The authors declared that they have no competing
interests.
References
1. Goffman E. Stigma: notes on the management of spoiled identity.
Englewood Cliffs: Prentice-Hall; 1963.
2. Corrigan PW, Kosyluk KA. Mental illness stigma: types, con-
structs, and vehicles for change. In: Corrigan PW, editor. The stig-
ma of disease and disability. Washington, DC: American
Psychological Association; 2014.
3. Sartorius N, Gaebel W, Cleveland H-R. WPA guidance on how to
combat stigmatization of psychiatry and psychiatrists. World
Psychiatry. 2010;9:131–44.
4. Stuart H, Arboleda-Florez J, Sartorius N. Paradigms lost: fight-
ing stigma and the lessons learned. New York: Oxford
University Press; 2012.
5. Corrigan PW, Morris SB, Michaels PJ, et al. Challenging the public
stigma of mental illness: a meta-analysis of outcome studies.
Psychiatr Serv. 2012;63:963–73.
6. Pescosolido BA, Martin JK, Long JS, et al. "A disease like any
other"? A decade of change in public reactions to schizophrenia,
depression, and alcohol dependence. Am J Psychiatr. 2010;167:
1321–30.
7. Harmon-Jones E, Winkielman P. Social neuroscience: integrating
biological and psychological explanations of social behavior. New
York: Guilford Press; 2007.
8. ACGME/ABPN. The psychiatry milestone project: the accredita-
tion council for graduate medical education, and the American
board of psychiatry and neurology, 2013.
9. Griffith JL. Neuroscience and humanistic psychiatry: a residency
curriculum. Acad Psychiatry. 2014;38:177–84.
10. Griffith JL. Teaching psychiatry residents how to manage stigma: a
curriculum grounded in social neuroscience and the social psychol-
ogy of stigma. In: 40th Annual Meeting of the American
Association of Directors of Psychiatric Residency Training.
Austin, Texas, 2011.
11. Griffith JL. Workshop: Interviewing patients who hate or fear psy-
chiatrists. In: 163rd Annual Meeting of the American Psychiatric
Association. New Orleans, 2010.
12. Jones E, Farina A, Hastorf H, et al. Social stigma: the psychology of
marked relationships. New York: Freeman; 1984.
13. Crocker J, Major B, Steele C. Social stigma. In: Fiske S, Lindzey G,
editors. The handbook of social psychology, 4th edition, volume 2.
Boston: McGraw-Hill; 1998.
14. Kurzban R, Leary MR. Evolutionary origins of stigmatization: the
functions of social exclusion. Psychol Bull. 2001;127:187.
15. Beer J, Mitchell J, Ochsner K. Multiple perpsectives on the
psychological and neural bases of social cognition. Brain
Res. 2006;1079:1–3.
16. Griffith JL. Religion that heals, religion that harms: a guide for
clinical practice. New York: Guilford Press; 2010.
17. Chiao JY. Neural basis of social status hierarchy across species.
Curr Opin Neurobiol. 2010;20:803–9.
18. Botvinick M, Braver T, Barch D, et al. Conflict monitoring and
cognitive control. Psychol Rev. 2001;108:624–52.
19. Greene JD, Nystrom LE, Engell AD, et al. The neural bases of
cognitive conflict and control in moral judgement. Neuron.
2004;44:389–400.
20. Chiaramelli E, Sperotto R, Mattioli F, et al. Damage to the ventro-
medial prefrontal cortext reduces interpersonal disgust. SCAN.
2013;8:171–80.
21. Decety J, Yang C-Y, Cheng Y. Physicians down-regulate their pain
empathy response: an event-related brain potential study.
Neuroimage. 2010;50:1676–82.
22. Kohrt BA, Blasingame E, Compton MT, et al. Adapting the
crisis intervention team (CIT) model of police–mental health
collaboration in a low-income, post-conflict country: curricu-
lum development in Liberia, West Africa. Am J Public Health.
2015;105:e73–80.
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