Motivation and emotion/Book/2016/Overcoming social stigmas

"The single most important barrier to overcome in the community is the stigma and associated discrimination towards persons suffering from mental and behavioural disorders."

- World Health Organization (2001)

Overview
Imagine you are experiencing personal growth. This could be that you feel that you are maturing, or perhaps that you have developed new values, or new healthy habits. It can also include the eradication of a stigma. Think back, have you ever previously held a stigma against a certain group of people that is different for you now? Have you ever wondered why you held the stigma in the first place, or what motivated you to change it? Finding answers to these questions provided the motivation for this chapter's topic.

The topic of stigmatisation and its associated topics of discrimination, stereotyping, and prejudice is broad and studied across different disciples of research (Dovidio, Hewstone, Glick, and Esses, 2010). Specifically these topics are of interest to the disciples of: anthropology, political science, neuroscience, social psychology, and sociology (Dovidio et al., 2010). The application of research within this field is of interest to: lawmakers, clinicians, public health workers, educators, and the media (Dovidio et al., 2010).

Stigmas can have profoundly negative effects on people's lives. Directed towards others, they are not directly harmful to those who hold them. This chapter is a chance to explore the reasons why people hold stigmas against others that they themselves did not come up with, and investigate what motivates people to change or abandon their stigmas. This chapter aims to address the social nature of stigmas in answering the question of why do some people abandon some of their stigmatic views over time?

Definitions
The terms below have specific meanings in psychology. Their meanings are separate to each other, but also related to each other. Other definitions of these terms exist that apply in other disciples as well as within psychology (Dovidio, Hewstone, Glick, & Esses, 2010). The following definitions represent the appropriate ones used in contemporary social psychology research.

Prejudice
Allport (1954) as cited in Dovidio, Hewstone, Glick, and Esses (2010) defined prejudice as an antipathy people hold against others based on an unsound generalisation which is inflexible to change. It can be directed towards individuals or groups, and it can be an internalised feeling or expressed as hostility (Dovidio et al., 2010). Prejudice is both an attitude held by individuals, as well as an attitude that exists within the structures of larger groups (Dovidio et al., 2010). Allport’s definition continues to be the predominant definition used by researchers (Dovidio et al., 2010).

Stereotype
A stereotype is a simple generalised model of what a group of people are like, which allows people to form opinions about others without needing to reassess beliefs associated with the stereotype (Heilman, 2012). Stereotypes are often thought of as being stubborn, often incorrect beliefs people have about other groups which are inflexible to change (Dovidio, Hewstone, Glick, and Esses, 2010). However this is not universally the case and modern research in the area sees stereotypes as functional and dynamic, classifying them as cognitive schemas, rather than the result of faulty thinking (Dovidio et al., 2010; Heilman, 2012). Stereotypes provide both helpful and unhelpful simplifications of the world to people (Dovidio et al., 2010; Heilman, 2012). As Figure 1 illustrates they are believed to be strongly influenced by social group membership, and can therefore play a role in promoting discrimination against others (Dovidio et al., 2010; Heilman, 2012).

Discrimination
Discrimination was defined by Allport (1954) as cited in Dovidio, Hewstone, Glick, and Esses (2010) as active negative behaviour directed towards "others" (groups or individuals). The behaviour is typically inappropriate or unfair (Dovidio et al., 2010). Discrimination therefore leads to harm or disadvantage (Dovidio et al., 2010). When prejudices forms a part of society such as in laws or in public policies, they can form the basis of an institutional discrimination where individual members are not aware they hold a prejudice due their in-group membership and acceptance of the status quo (Dovidio et al., 2010).

Stigma
Stigma is different but related to discrimination and prejudice. As Goffman (1963) notes, stigma is an ancient term dating back to the ancient Greeks. In those ancient times people could be physically marked to classify them as belonging to a certain social group of particularly low status (Goffman, 1963). People could be marked as being a slave, or a criminal, or even as someone to be publicly avoided (Goffman, 1963). The Christian use of this term also comes from the Greek meaning: crucifixion was a disgraceful way to be executed, so it would indeed be seen by others as disgraceful to carry such marks in the ancient world (Goffman, 1963).

The term stigma is therefore used to mean personal attributes people have that devalue them in the eyes of others (Goffman, 1963). People who are stigmatised experience feelings of deep shame, inadequacy, tainted, worthlessness, and other negative feelings (Goffman, 1963). The most importance difference between prejudice and stigma is that a prejudice leads to discrimination in the way others are treated, whereas stigmatisation leads to people being devalued and dehumanised. Stigma therefore is a source of prejudice, however prejudice can also arise as a negative stereotype.

Who does it affect and how common is it?


Stigma is common, and people who have a disease or a mental illness are generally associated with being at highest risk of being negatively affected by stigmatisation (Puhl & Heuer, 2010). This has unfortunately meant that people who are already suffering from disease or infirmity have a higher risk of being stigmatised by others, including by healthcare workers (Puhl & Heuer, 2010; Stubbs, 2016). Specific examples include people with communicable diseases like Tuberculosis and Typhus, as well as sexually transmitted diseases such as HIV and Hepatitis B, and even some non-communicable disease including obesity and other lifestyle related illnesses (Puhl & Heuer, 2009, 2010). People with mental health conditions are also highly stigmatised, examples include: depressive disorders, anxiety disorders, epilepsy, and behavioural disorders (World Health Organization, 2001).

Indeed, labels for mental illness are used as social slurs whereas physiological illness labels are not. Negative social stereotypes and stigmas can be observed across different forms of media (books, film, television, radio, newspapers, and stage) (Dovidio, Hewstone, Glick, & Esses, 2010; Lawson & Fouts, 2004). Lawson and Fouts (2004) found that a majority of Disney animated films released through to 2001 made use of mental illnesses to verbally denigrate characters.

Stereotypes and stigmas have been used in films to visually distinguish protagonists from villains. How many movies can you think of where the protagonists and antagonists are clearly distinguishable by their visual appearance? For example, in 'The Wizard of Oz' the Wicked Witch of the West is depicted an ugly and vile creature with a wart on her face, whereas the Good Witch of the North is depicted as being very beautiful (LeRoy & Fleming, 1939). Another good example is the 1984 film 'Dune': in the movie the main protagonist is depicted as being a young, healthy, straight, and attractive male; while Baron Vladimir Harkonnen being one of the film's main antagonists is a heinously ugly, sickly, overweight, homosexual man who also has unsightly warts on his face (De Laurentiis & Lynch, 1984)! Visual stigmas of this kind are very powerful, I can remember closely associating facial warts with the 'Wicked Witch' as a child. These examples provide evidence of stigmas, but not evidence that exposure to such stereotypes in film and media affects socially held stereotypes (Dovidio, Hewstone, Glick, & Esses, 2010).

The examples provided only serve as a very limited representation of stigmatised groups. Indeed anecdotes in this instance are far more powerful for understanding the negativities associated with stigma than the clinical descriptions found in academic journals. Some relevant anecdotes are linked to in the external link section, the IKW Video is particularly good at explaining some of the effects of mental health stigma on people's lives. There seems to be no limit to who can be stigmatised, anyone who could find themselves in a minority group in some place at some time could potentially face being stigmatised by others.

Some groups are disproportionately affected by the effects of stigma and prejudice (Puhl & Heuer, 2009). Because prejudice and stigma are largely social beliefs, many groups that are the victim of a social stigma or prejudice appear to cope well and not to be affected by the expected negative outcomes (Croker & Major, 1989; Dovidio, Hewstone, Glick, & Esses, 2010). Indeed many groups appear to use stigmas or prejudices directed towards them to strengthen their own group and individual self-concepts (Croker & Major, 1989; Dovidio et al., 2010). These observations contradict stereotype threat theory, which predicts that negative stereotypes are a self-fulfilling negative prophecy for individuals who are aware of them (Steele & Aronson, 1995).

How do stigmas arise?
As previously mentioned, humans have been stigmatising each other for thousands of years. The perception of ‘race’ can be a stigma, based on specific social constructs (Andreasen, 2000). The nature of these social constructs have changed over time, for example in the Biblical book of Ezra people living in different cities of ancient Canaan were perceived to be a different ‘race’ to the Hebrew people. By the 19th and early 20th centuries CE, the predominant view amongst the academics of the age was that different human races was a biological reality (Andreasen, 2000). The dominant view today is that race is a social construct, and not an objective reality based on biology (Andreasen, 2000). The 2014 Lateline interview with Noel Pearson contains a great discussion on the topic of ‘race’ in Australia today, where Pearson argues that the Australian Constitution should not contain the word 'race'.

Stereotypes and prejudices arise in individuals with little to no awareness or intent on the part of individuals (Dovidio, Hewstone, Glick, & Esses, 2010). Because this process happens before people have a chance to consciously object to being indoctrinated by unhelpful beliefs, it seems inevitable that most people will develop them. Social groups then provide the justification for people to continue holding unfair negative perceptions of others (Dovidio et al., 2010). However, people who are motivated to change their negative attitudes and behaviours directed towards others can do so (Dovidio et al., 2010).

Social identity and stigmas
Social identity theory was first conceived in the 1970’s. The theory argues that people possess two identities: an inward looking ‘personal identity’, and an outward looking ‘social identity’ (Brown, 2000). Since the theory’s inception it has been widely used as a way to explain psychological problems that other theories in psychology appeared unable to solve (Brown, 2000). The theory argues that social identities are a source of bias towards in-group biases, beliefs, and behaviours when compared to alternative groups that an individual is not a part of (Brown, 2000). Social identity theory predicts that individuals will denigrate, stigmatise, and discriminate against people who are outside of their social groups (Brown, 2000; Dovidio, Hewstone, Glick, & Esses, 2010). Social identity theory also predicts negative outcomes from self-association due to awareness of negative stereotypes against an individual’s social group (Steele & Aronson, 1995).

Because people are members of multiple social groups, they can be exposed to contradicting social stereotypes (Brown, 2000; Dovidio, Hewstone, Glick, & Esses, 2010). This situation motivates people to re-evaluate stigmas and stereotypes they hold. Even though people hold strong stigmas against others, they somewhat paradoxically value equality and social justice as basic human rights (Dovidio et al., 2010). For this reason, we might expect that some people will feel motivated to re-evaluate strongly held prejudices and stigmas in order to personify these values.

How do people express sigma and prejudice?
People are motivated to express their stigmas and prejudices in different ways. People with a higher self-esteem are more likely to openly denigrate others (Dovidio, Hewstone, Glick, & Esses, 2010). Other people manage to suppress their stigmas for a variety of reasons, not the least of which being that prejudices and stigmas are largely social beliefs rather than individualistic ones (Croker & Major, 1989; Dovidio et al., 2010; Plant & Devine 1998). Stigma can result in relentless bullying, including cyberbullying, which can lead to suicide or even death. Monica Lewinsky delivered a moving TED Talk in 2015 articulating her experience with cyberbullying in 1998 - before we even had a word for what it was!

People can also face harsh bullying and cyberbullying due to their occupations. Alyssa Funke was a young lady who was described as a straight-A university student who was studying chemistry in Wisconsin in 2014 (Gorman & Boyle, 2014). Alyssa took part in a pornography film, and was subsequently cyberbullied by her former High School classmates (Gorman & Boyle, 2014). The ordeal resulted in Alyssa feeling "unbearable grief", so she deleted her Facebook account (Gorman, R. & Boyle, 2014). The cyberbullying continued, and Alyssa ultimately committed suicide (Gorman & Boyle, 2014). Even after her death, online denigrations against her did not stop (Gorman & Boyle, 2014). A pornography actress named Miriam Weeks who went through a similar experience was prompted to share her story on xoJane, describing her own experience with being stigmatised for her occupation, and clearly empathising with Alyssa's decision.

Other people are treated in ways that are dehumanising. One such story was shared by Martin Pistorius in a TED Talk. Martin lived with locked-in syndrome for about thirteen years from the time he was about sixteen. While living with locked-in syndrome, Martin experienced physical, verbal, and even sexual abuse from his caregivers. His situation changed when one of his caregivers, perhaps through intuition or empathy, felt that he was conscious and had his parents arrange rehabilitation so he could communicate.

Expression of stigmas is largely due to social perception. For example, the AIDS epidemic in the 1980's was accompanied by exceptionally high levels of stigma across the world that deeply penetrated the health profession (Parker & Aggleton, 2003). The social denigration of sufferers with HIV/AIDS was acknowledged by the United Nations as its own threat to the health of people with the conditions (Parker & Aggleton, 2003). I remember feelings of apathy directed towards people who had HIV as a young person in the mid to late 1990's. Yet I had never met a person with HIV at the time! At the time no one had explained to me that many of the early people who got HIV contracted it before it was widely known about.

Self-regulation
Perhaps the most likely candidate for positive change is through self-regulation. As already discussed, people possess conflicting beliefs about others in society. These internal psychological conflicts have been widely studied but are not too well understood (Brown, 2000; Dovidio, Hewstone, Glick, & Esses, 2010).

Individually held stigmas appear to arise as a result of a natural cognitive process, which is influenced by social groups and the social setting, rather than being the result of intentional malice directed towards others (Dovidio, Hewstone, Glick, & Esses, 2010). Although most people do view equality and social justice as important values, they also hold conflicting values which pull people in a direction towards intolerance and stigma (Dovidio et al., 2010). For example, this includes adherence to social norms which may be discriminatory, as well as group values which the individual feels strongly about such as religious beliefs (Dovidio et al., 2010). It appears to be very difficult to challenge whole world views held by people!

Motivation for change
People are unlikely to override a natural cognitive process without a motivation that is stronger than the cognitive process that produced the unwanted behaviours. Stigmas are also notoriously difficult to change through intervention strategies (Batson et al., 1997). Plant and Devine (1998) note that people have been observed to suppress their prejudices for certain audiences, whilst not being motivated to change the underlying stereotype or stigmas they hold. However, over time the social setting can provide a motivation for change, by making it more difficult for people to express their prejudices (Plant & Devine, 1998; Plant, Devine, & Brazy, 2003).

Plant and Devine (1998) identified two principle motivators that caused people to willingly suppress their prejudices. One motivator is internal, where people try to act in accord with egalitarian values (Plant & Devine, 1998). The other is external, where people seek to avoid negative responses from others (Plant & Devine, 1998). These motivators are complimentary but produce different outcomes as discussed below.

Internal motivation
People with high internal egalitarian-based motivation are able to regulate their prejudice related behaviours more regularly (Plant & Devine, 1998; Plant, Devine, & Brazy, 2003). Plant and Devine (1998) expect that this likely represents a shift towards more positive attitudes in general in such individuals. Perhaps most importantly of all, they also found that people with an internal motivation to behave in a non-prejudiced way were not lacking in their social identities, and was not related to self-presentation. This is great news for anyone with a strong motivation to make personal progress!

External motivation
People with a high external motivation are driven to avoid negative responses from others (Plant & Devine, 1998). This type of motivation is related to social identity, and to self-presentation (Plant & Devine, 1998). Externally motivated people are only motivated to suppress their prejudices in public, or in front of certain audiences (Dovidio, Hewstone, Glick, & Esses, 2010). This is not to imply that individuals who regulate their negative behaviours towards others due to external motives are bad people just that the motivation appears to be weaker when compared to internal motivation. Dovidio et al. (2010) note that both motivations play a helpful role in reducing prejudice.

Triggering motivation for change
Several methods to elicit a positive response from people have been suggested and will be discussed briefly in the following paragraphs. One downside to inflicting our will upon others, is that even if we have the best intentions it can be counter-productive. It is important to recognise that different people respond to different intervention strategies in different ways, and that in this area what works well with some people may not work for others.

Thought suppression
Thought suppression involves strategies for individuals to follow which are designed to suppress the area of concern (Dovidio, Hewstone, Glick, & Esses, 2010; Wenzlaff & Wegner, 2000). This method has proved useful for some people, although people for whom this intervention is helpful are typically those who have a strong personal desire for change anyway (Dovidio et al., 2010; Wenzlaff & Wegner, 2000). For the majority of people it seems that thought suppression invokes a counterproductive effect either strengthening the prejudice addressed or redirecting the cognitive energy towards denigrating another group (Dovidio et al., 2010)! The process is also intrusive and cognitively taxing (Dovidio et al., 2010; Wenzlaff & Wegner, 2000). Researchers remain sceptical about the clinical use of this method for long term change in attitudes (Dovidio et al., 2010; Wenzlaff & Wegner, 2000).

Empathy
Empathy is a great tool to elicit motivation for change. Empathy is a complicated cognitive process that is not fully understood, however it involves a person mirroring the emotions of another person (Elliott, Bohart, Watson, & Greenberg, 2011). Public health workers, therapists, and clinicians make use of empathy to build rapport with clients, and to decrease anxiety and fear in their clients (Elliott et al., 2011). Although not proven, the process of empathising with healthcare clients in this way is believed to change attitudes of healthcare workers in a positive direction. This scenario happens in combination with contact.

Research has shown that empathy can help to break social stigmas (Batson et al., 1997; Parker & Aggleton, 2003). Role-playing on the other hand appears to have no effect on stigma (Stubbs, 2016). Overall, the literature shows that empathy does work at least in the short term to change attitudes based on stigma (Batson et al., 1997; Stubbs, 2016). One clear advantage of empathy is that it does not involve telling people information that contradicts their beliefs (Batson et al., 1997).

Contact
Contact or interaction between people in stigmatised groups has been shown to have multiple benefits related to stigma reduction (Elliott et al., 2011; Rose, Thornicroft, Pinfold, & Kassam, 2007). There is stronger evidence of contact reducing stigmas than there is for any other intervention method (Rose et al., 2007; Stubbs, 2016). When studied in the clinical setting the effect reduced over time (Rose et al., 2007; Stubbs, 2016). This, however, is to be expected if people do not feel motivated, and suggests that the clinical application may not be as effective as self-motivated individuals are to reduce stigmas.

Conclusion
Although stigmas are notoriously hard to change, they can change. They are observed to change in response to shifting attitudes in society, as well as in response to factors linked to motivation (empathy and contact). The literature is limited because most journal articles are focused on mental health, leaving many other stigmas such as those directed at sex workers and others largely unexplored.

The literature makes it clear that many people are unwilling or not ready to challenge stigmas which often form integral parts of their world views. Still others are willing to change, but may find overriding automatic habitual cognitive processes stressful and difficult to maintain. There also exist other barriers to motivation including social norms, religious beliefs, and other world-views. Change does not appear to be a process easily forced, rather ways to improve people's motivation to change should be explored in the future.

Stigmas are strongly held beliefs that arise from an individual's psyche without warning or intention of malice. People who hold stigmas need to feel safe to explore other alternative views. These beliefs people have in social justice and equity are a likely source for self-motivation to change. While several motivating factors for change have been identified, and it seems clear that motivation plays a central role in lasting change, further research needs to be undertaken to more clearly understand why people become motivated to change their own views without prompting by intervention.