Department of Psychiatry and Behavioural Sciences, Middlesex Hospital, London
Correspondence: Rahman Haghighat, Adult Department, Tavistock Clinic, 120 Belsize Lane, London NW 3 5BA, UK. E-mail: r.haghighat{at}lycos.com
Declaration of interest Funded by a grant from University College London Trustees.
See editorial, pp. 197-199,
this issue
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ABSTRACT |
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Aims To develop a theoretical foundation to help comprehend the core meaning of stigmatisation and to guide practical anti-stigmatisation measures.
Method Personal reflection; re-interpretation of stigmatisation and reformulation of the relevant concepts.
Results Emergence of a unitary theory of stigmatisation.
Conclusions Based on the structure of stigmatisation one could explore six levels of intervention in anti-stigmatisation campaigns: the cognitive level educational intervention; the affective level psychological intervention; the discrimination level legislative intervention; the denial level linguistic intervention; the economic origin political intervention; the evolutionary origin intellectual and cultural intervention. As destigmatisation has to challenge fundamental human tendencies, anti-stigmatisation campaigns have to be continuous, non-stop, open-ended projects aiming at keeping alive thought processes that moderate and humanise the pursuit of self-interest and the urge to survive in a competitive world.
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INTRODUCTION |
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ORIGINS OF STIGMATISATION |
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The brain also tends to associate negative events (which are rarer then neutral and positive events) with other rarer objects, for example with members of minority groups (themselves less numerous and more distinctive) rather than with the majority (Hamilton & Gifford, 1976; Hamilton & Sherman, 1989; Stroessner & Mackie, 1993). This tendency comes from distinctiveness by rarity and the association of distinct events and objects. Thus the brain associates cases of crime (by nature, rarer and more distinctive than instances of non-crime) with minorities rather than majorities.
Constitutional factors, in the service of the pursuit of self-interest (Fig. 1), are likely to lead to judgements that are unfair on others, yet they can be adaptive by the very small probability of protection they could offer: for example, one might avoid danger by preferentially weighting negative evaluations about people.
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Constitutional factors, although biological, are considered separately from other evolutionary factors (see below), as the former are more vegetative responses and the scope of anti-stigmatisation in the two areas cannot be the same.
Psychological origins
Humans, although generally not endorsing the misfortune of others, are
willing to use unfortunate others to feel happier about
themselves. People in groups in which reward is equally distributed are less
satisfied in comparison with people in groups that include an unfortunate
person, although they are likely to acknowledge the unfairness of the
situation (Brickman, 1975).
Further, people subjected to threats, failures and the frustrations of
everyday life and those with low self-esteem tend to derogate others in order
to bolster their own self-esteem and feelings of well-being
(Wills, 1981;
Gibbons & Gerard, 1989). This phenomenon is similar to someone feeling eloquent when he/she considers
another inarticulate, or beautiful when he/she considers another ugly. Thus,
stigmatisers benefit from the presence of the stigmatised, the latter
providing them with psychological dividends: examples they could consider as
worse than themselves in order to redress the balance. On the
contrary, people with higher intelligence and higher self-esteem are more
likely to hold positive attitudes towards patients with mental illness
(Nunnally, 1961), probably
because they would not need to degrade those with mental illness in order to
feel intelligent or positive about themselves.
Stigmatisers, indeed all of us, when faced with the stigmatised are likely to feel uncomfortable by the mere fact that bizarre behaviour or facial disfigurement, for example, could challenge our norms, values and expectations. To reduce the tension we avoid the stigmatised, which in behavioural terms (Bandura, 1977) means a reduction in tension and thus psychological gain. To deal with any feelings of guilt that this may cause, we may resort to theories such as the Just World hypothesis (Lerner, 1980). The idea that people can experience illness or injury without being responsible threatens us, and we need reassurance that the same fate is not going to befall us. Some of us may then propose that stigmatised or their parents have done something wrong and are being punished deservedly for their sins. This allows the pursuit of psychological self-interest without unbearable guilt.
Promoting the idea of free will and the concept of self-infliction, e.g. in addictions, although containing partial truth, is indeed used to allay the guilt related to being a stigmatiser and is an application of the Just World belief.
Economic origins
The stigmatiser's discourse has economic aspects as well. "I must
avoid danger to survive and compete": to increase one's access to
resources, stigmatisation of rivals is used as a weapon in socio-economic
competition (Sherif et al,
1961; Hatfield et al,
1978). Stigmatisation is likely to be more intense in more
competitive, self-seeking societies, moderated by the ease of availability of
resources. The number of lynchings of Blacks in the USA between 1882 and 1930
varied in line with economic indices such as the value of cotton. As the
economy worsened, more Blacks were lynched; as it became better, fewer Blacks
were lynched (Hovland & Sears,
1940; Hepworth & West,
1988). Of course the relationship between the price of cotton and
lynching is a correlation, but what could be the superordinate cause bringing
about their covariation? The likely interpretation is that competition for
scarce economic resources intensifies hatred and stigmatisation. Again, these
disturbing findings are likely to relate to self-interest.
Nowadays, the expression of discrimination may not be lynching. A sports team may accuse another team of drug abuse or disgraceful social behaviour. Here, the former is not necessarily projecting one of its own attributes onto the stigmatised; rather, it may project one out of a list of socially objectionable attributes in order to discredit the rival and promote its own opportunities.
Evolutionary origins
Stigmatisation, as a tactic for survival and reproduction, is a discourse
implying a genetic push towards discrimination. This suggests
that genes make humans and animals discriminate in order to avoid dangers,
including natural dangers (snakes, heights, darkness), illness (rotten food,
those with a contagious disease), mechanical danger (falling objects, those
who pose a physical threat) and ideological danger (deviants,
non-conformists and psychopaths)
(Buss, 1999). Those who are
poor bets genetically (carrying genes for a disease), sexually (unattractive,
disabled, resourceless), in terms of survival (social parasites,
infected people) and in terms of security (psychopaths,
criminals, exploiters) are avoided (Buss,
1999; Gilbert,
2000) and there is competition with potential rivals for
resources, all in the service of genetic interest. Thus, those who are
potentially violent because of an underlying mental illness, those who are
likely to carry genes for a mental disorder (e.g. manic-depressive illness)
and those who are unable to control resources (such as people actively
suffering from depression) are stigmatised in the genetic interest of
stigmatisers.
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EMERGENCE OF A UNITARY THEORY |
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Stigmatisation involves self-sheltering and self-seeking behaviour. It is a protective device for the stigmatiser and, in a good number of cases, unfair on the stigmatised, as the latter may simply be the victim of a rumour or may not be the one among the stigmatised who would cause harm. The stigmatiser, on each occasion of avoiding the stigmatised, draws primary gain from reducing his or her anxiety and is thus powerfully reinforced. The stigmatiser also draws secondary benefits from stigmatisation by avoiding possible loss, danger and victimisation and by increasing his or her chances of economic survival.
What is the origin of self-interest? Is it biological or acquired? Is it innate or learned? Perhaps a mixture of all? Constitutional, psychological, economic and evolutionary merely constitute a paradigm for the purpose of better understanding, and in practice they all intermingle, overlap, work together and interrelate.
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MOTIVATIONS FOR DESTIGMATISATION |
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STRUCTURE OF STIGMATISATION |
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EDUCATIONAL INTERVENTION |
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Questionnaires measuring cognition rather than attitudes
What one measures by attitudinal questionnaires are cognitive
hypotheses by subjects themselves of what they would think about, or feel or
do towards the general category of patients with (a given) mental illness. The
results of the surveys are then neither a measure of behaviour nor a measure
of feelings towards the larger group of patients and therefore are not a
measure of attitude because the latter has affective and sometimes behavioural
components as well. The mind of a person subjected to a cognitive task such as
a paper-and-pencil survey is likely to function on a different level than when
subjected to the emotional stress of encountering real-life disturbed
behaviour. Extrapolating from psychosocial studies
(Stephan & Stephan, 1985;
Dijker, 1987;
Mackie et al, 1989;
Wilder & Shapiro, 1989;
Islam & Hewstone, 1993), which demonstrated that arousal increases the power of stereotypes and limits
access to one's cognitive reserves, one could conclude that the anxiety and
fear about personal safety and self-interest resulting from an actual
encounter with an acutely ill patient is likely to disperse at least part of
the cognitive effect of previous public education.
Yet, cognitions do matter, as the inevitable awareness of the stigmatised of the cognitive elements of people's attitudes puts the former in a position in which they feel vulnerable to what others may choose to do, whether in practice they do it or not.
People selecting the information
The input that leads to a new emotional experience for the public is likely
not to be that they are told that patients are curable but that they do not
hear of any more acts of violence committed by someone with mental illness.
The development of a cure for mental illness is likely to reduce
stigmatisation not when it is just given as cognitive data but when it is
shown to be effective. Any possible effect of public education is likely to
burn out with time as people tend to seek out information that confirms their
pre-existing stereotypes (Skov &
Sherman, 1986; Pendry &
Macrae, 1994). Data consistent with stigmatising attitudes receive
more attention and are rehearsed more frequently
(Fiske & Neuberg, 1990).
Although people with a better understanding of mental illness self-reportedly
stigmatise less (Link et al,
1987; Brockington et
al, 1993), the correlation may mean that those already less
likely to stigmatise hold onto the information, confirming their relatively
positive stereotypes, rather than that the knowledge per se makes
them less likely to stigmatise.
Subjects who show negative attitudes at baseline are likely to refuse to be re-interviewed post-campaign (Wolff et al, 1996a) and information inconsistent with one's stereotype is likely to be refuted or denied (O'Sullivan & Durso, 1984). In campaigns for changing attitudes towards minority groups (Devine, 1995), the information reaches those who already agree with it. The pressure involved in counterstereotypical messages given to people in anti-stigmatisation protests (Macrae et al, 1996) might make people comply on the surface, while suppressing their stigmatising attitudes, so that overt acts of discrimination are either converted into subtler forms or inhibited, with the possibility of strong rebound (Macrae et al, 1994).
Talking to the feelings versus imparting information
The stigmatiser, like anyone else, has involuntary, unconditioned emotional
responses (arousal, anxiety and fear) to certain events (e.g. serious
accidents or death) and conditional responses to whoever reminds them of these
events (someone lacking sanity, a mutilated person, a terminally ill person).
According to behavioural theory, people take steps to avoid negative events
and so the stigmatiser is likely to avoid the stigmatised to get away from the
anxiety and fear that they arouse (Berger
& Luckmann, 1966; Schutz,
1971).
Information alone is unlikely to demolish stigmatising attitudes because they are three-storey structures with a cognitive level but with two other levels as well. Anti-stigmatisation is likely to need something deeper than logic. To lecture people that patients with mental illness are not dangerous and that people should not worry about them is like saying to someone who has flight phobia that the aeroplane is safe and that he should not hesitate to board.
Research (Bodenhausen, 1993; Bodenhausen et al, 1994; Jussim et al, 1995) suggests that it is the feeling component rather than the cognitive component of attitudes that determines people's social judgement. Although some stigmatising attitudes are adopted consciously (spreading rumours about an economically rival group), stigmatising attitudes are mostly established through the involuntary process of classical conditioning (Staats et al, 1962), in the same way that phobias are. Thus, if every time one hears the word schizophrenic on TV (conditioned stimulus) there is news of murder (unconditioned stimulus), one is going to associate the fear in relation to the murder (unconditioned response) to the word schizophrenic (conditioned stimulus) and the word is going to bring about the same fear and anxiety (conditioned response) after a certain number of associations.
To make sense of their fear, stigmatisers deploy explanatory models. The cognition that schizophrenics are violent is likely to be part of the subsequent syllogism that stigmatisers use as a semantic back-up for their underlying emotion rather than the cause of it. Offering them the cognitive model schizophrenics are not violent is unlikely to fix the already established autonomic circuit of arousal, fear and anxiety because mere information is likely to fall apart when stigmatisers feel primitive, irrational emotions. They have, in essence, an affective problem. They need a new emotional experience rather than a new explanatory model that they are unable to use and that would not fit their system, however open-minded and scientific the explanatory models of the organisers of a campaign are.
Nevertheless, this idea should not be taken to such extremes as to mean colluding with stigmatisers. Educational campaigns are likely to have, at the very least, the effect of challenging stigmatisers' attitudes, proposing alternative attitudes and emphasising the presence of anti-stigmatisation pressure groups and stakeholders. Psychosocial research on stigmatising attitudes towards ethnic minorities shows that people's awareness of the discrepancy between how they behave and how they think they should behave can cause emotions such as guilt and discomfort, at least in some; this is likely to prevent them from acting on their stigmatising attitude in the future (Monteith, 1996) but without necessarily changing those attitudes. It is likely that what could be achieved by educational campaigns is either nothing or a minor positive shift in moderately negative or relatively positive stereotypes, which then remain open to long-term challenges by constitutional, evolutionary, economic and psychological contingencies based on self-interest.
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INTERVENTION AT THE AFFECTIVE LEVEL |
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From contacts with patients to exodus from hostel neighbourhoods
In contacts, the ever-present risk is that of non-generalisation of
positive feelings generated towards the stigmatised persons
encountered to the category to which they belong. Extrapolating psychosocial
findings on students and ethnic minorities
(Wilder, 1984;
Johnson & Hewstone, 1992;
Van Oudenhoven et al,
1996) to campaigns in mental health suggests that providing the
public with contacts with a successfully treated patient is likely to create a
new subtype in their mind: "She is an exception. I have seen others
worse than her." As exposure to further strong disconfirming examples
continues, new subtypes are likely to be created "female
educated patients", "well-treated harmless patients", etc.
but the original stereotype is maintained. On the contrary, when the
contact person is typical of the stereotype with an additional
characteristic of, for example, pleasantness
(Wilder, 1984) or when the
contact happens in an equal-status cooperative context
(Desforges et al,
1991; Van Oudenhoven et
al, 1996), there may be a change in the stereotypes.
If substantiated, such hypotheses have to face other challenges in the real world. Among these is the finding that a larger number of examples is required to confirm a positive attribute in a stereotype and fewer contrary examples to disconfirm it (Rothbart & Park, 1986). This is consistent with the fact that people tend to weight negative information more heavily than positive information (Kanouse & Hanson, 1972). Therefore, exposure to a great number of positive contacts can be undone easily by a few salient items of news about a murder by a patient with mental illness or by a film involving the audience in an emotional contact with characters not elaborated according to social science laboratory formulas. Also, to work from within the stereotype in order to promote its improvement may paradoxically reinforce it because there is a fine line between using the stereotype without giving it undue salience and using it in a way that leads to its further reification.
Wolff et al (1996a) report increased contacts between local patients in a hostel and neighbours as a result of campaigns of public education that encouraged contacts between the two groups. They interpret this as an improvement in overall attitudes and behaviour "towards the mentally ill", taking for granted the generalisation from a few local patients to the category of patients with mental illness. What is also missed is that, after such contacts were encouraged, the mobility of neighbours over a 2-year period was significantly higher than that of people in a control street (Table 1).
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Those who moved out had shown no overall difference in stigmatising attitude pre-campaign compared with other neighbours, yet the likelihood that their attitudes were affected more negatively subsequent to the arrival of the hostel and the associated publicity, or that they corresponded to that subgroup who stigmatise in effect and not on survey papers, should not be left unmentioned. Of course, the significant difference in mobility might have occurred due to the presence of a more mobile group in the experimental street at baseline. Mobility is likely to be determined by socio-demographic factors and although there were highly significant disparities between the ethnicity and social class of the control and experimental groups (which already casts serious doubts on the comparability of results) one cannot conclude that the significant excess exodus from the experimental street was merely due to such class and ethnicity differences. The idea that an additional number of neighbours left the experimental street within 2 years to get away from the hostel becomes more probable when one considers that, according to the authors, 20% of the respondents at the initial interviews expressed concerns, one of which was worry about "a drop in house prices" (Wolff et al, 1996b) if patients were moved from hospitals into units in their areas. Although causality between contact and excess exodus cannot be proved, consideration of a significant mobility in an experimental group should be part of the interpretation of any such research. Those who move out of an area to avoid patients can have their negative attitudes reinforced by the mere act of distancing themselves, which would give them a feeling of relief (negative reinforcement). Also noteworthy are the notions of "phantom acceptance" (Goffman, 1963) and specious integration of patients in neighbourhoods with low social cohesion (Segal,1980), and so high mobility.
The dilemma is clear: on the one hand, if we present the public with dramatically improved patients they are likely to subtype them as exceptions; on the other hand, if we work from within the stereotype and present the public with typical patients, there might be some positive shift in the stereotype but there is also a risk of reinforcing the stereotype.
Focusing on the feelings of the public
If contacts with patients are fraught with dilemmas, how could one act on
the affective level of stigmatising attitudes? When one reflects on the
relative success of local targeted efforts at destigmatisation
(Lynch, 1987;
Quicke et al, 1990),
one opportunity is that in these workshop-like events there may have been more
opportunity for ventilation of anxieties of some of the target groups. These
campaigns, associated with discussion with peers and teachers,
reported a more pronounced improvement in preconceptions. There
has been no adequate interpretation of why this should be so, yet the
likelihood is that during some of these unstructured discussions
the fear and anxiety of participants are more or less ventilated. It would not
be adequate to tell people that patients are not dangerous, because what they
need is to feel free to say how fearful they were the other day when they
heard about a patient attacking someone in the street. Real concern for
patients starts by paying attention to the affective content of public
attitudes. Destigmatisation, if it is ever to be successful, needs to provide
forums for the expression of fears, in which people can speak up, ask
questions, challenge and communicate their worries. If taken seriously and
relieved of their anxiety they are likely to take seriously the same feelings
in the patients. Large group meetings with the help of a psychotherapist,
facilitator or trained social workers are likely to allow ventilation of
public feelings in neighbourhood centres, youth organisations, community
services, churches, libraries and schools.
Labouring in the arts' workshop
The arts would identify its function as not always copying reality but as
modifying and representing it in new forms. An aspect of work on the affective
component of the stigmatising attitude would be to acquire a weapon: producing
works of art, writing popular novels or making films with the help of
interested patients and psychiatrists in collaboration with artists. These
works of art are likely to act on the feelings of the public at a level where
the affective component of their attitude resides, rather than at a cognitive
level. There is much scope for acting on the public's feelings by portraying
the struggle and revaluation of patients with mental illness. A relevant
example is The Marie Butler Story, a film produced in the USA by CBS
in collaboration with the National Alliance for the Mentally Ill (NAMI) about
the sacrifices and successes of an institutionalised woman. The
risk of subtyping is likely to reduce when works of art depict a
typical patient with typical struggles who
improves and develops into a person seen by viewers and readers as someone
like themselves. Work with TV professionals needs to be a business of having
anti-stigmatising messages subsumed under new emotional experiences for the
viewers. Generous arts and media awards would guarantee cooperation.
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LEGISLATIVE INTERVENTION |
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The exercise of discrimination can be subtle, such as sitting apart or not smiling, or flagrant, such as rejection of an employment application or refusing to rent out accommodation or not allowing people on public premises. The legislative system needs to be encouraged and/or put under pressure through advocacy and lobbying by anti-stigmatisation watch-dogs created within psychiatric associations. The latter, networking lawyers, members of parliament and human rights organisations should identify gaps in the legal protection and promote enacting laws that allocate sanctions on gross discriminatory behaviour. Other legislation needs to promote positive discrimination in the sense that employers should be rewarded for having a quota of employees from those who suffer from mental illness and providing them with training options and specific sick-leave provisions; landlords should have more obligation towards patients; and insurance companies should have some commitment to include cover for mental illness on their mainstream policies as a means of recognising the value of people with mental health problems and the ubiquity and acceptability of mental illness.
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POLITICAL INTERVENTION |
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Egalitarian non-competitive environments that encourage cooperative interdependence of all people for a superordinate aim of rewarding the whole society reduce inter-group hostility and prejudice (Sherif, 1966; Amir, 1976; Gaertner et al, 1993). The political philosophy of the state and its emphasis on unity and interdependence of people is likely to moderate the selfserving behaviour of its citizens and promote tolerance and respect for all, including the weak and the vulnerable, who are then seen as allies in the service of the higher cause. This is ambitious enough for it to be a task to which all citizens need to contribute, the task of the third millennium.
What we perhaps lack is a political ideology that would allow consideration of the environments from which people come rather than how much they have achieved. In many contexts, an important question all of us need to answer is whether the existential value of someone who has achieved more without having a mental illness is necessarily higher than that of another who has achieved less while having a mental illness. The difficulties facing some people with mental illness are just the same as those that would face anyone who developed mental illness after a lifetime of good mental health, and they cannot be used as a basis for measuring people's personal value.
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LINGUISTIC INTERVENTION |
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Linguistic intervention challenges and invites at the same time: challenges whoever has a stigmatising attitude, and invites whoever might be sympathetic enough to join the destigmatisers. Thus, to favour the use of a person with an experience of schizophrenia as opposed to schizophrenics is not necessarily mistaking linguistic symptoms for the social reality of the lives of these patients.
Reviewing brochures of advocacy organisations such as Mind (National Association for Mental Health) shows that linguistic intervention is one of the requests of patients and their advocates, and destigmatisation starts by paying attention to these requests. In changing their titles, patients assert that the existing orders of the world are not immutable and this can be their first step towards more autonomy. Their request does not need to be taken as a mere wish for a change of designation (Haghighat & Littlewood, 1995); it can also be seen as a tacit invitation by patients to others to review their stereotypes, indeed a request for a reconsideration of others' personal attitudes. In this perspective, linguistic intervention is an attempt to launch a debate on something wrong in stigmatisers' language in order to draw attention to something more sinister: a self-enquiry device that challenges the denial. As is the case with anti-stigmatisation protests (Macrae et al, 1996), linguistic intervention may lead to suppression of stigmatising attitudes, yet, unlike educational campaigns, this would not necessarily remain a pure cognitive enterprise in that it directly challenges stigmatising attitudes and is likely to arouse more emotions (e.g. constructive guilt) in some people and have at least some positive effect.
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INTELLECTUAL AND CULTURAL INTERVENTION |
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The fact that nature is what it is does not mean that one could not use judgement or morality to decide what is good for humans (Barash & Lipton, 1985). Yet, those who need to stigmatise in order to dominate would either downgrade the idea of morality as the instrument used by the weak (Nietzsche, 1886) or recommend a new morality in the service of power: "one has duties only toward one's equals; one may act as one sees fit toward beings of a lower rank, toward everything foreign to one" (Nietzsche, 1886). Thus, old and new morality can both be used in the service of domination. The Encyclopaedia Britannica (1998) mentions that "two books were standard issue for the rucksacks of German soldiers during World War I, Thus Spoke Zarathustra [by Nietzschel and The Gospel According to St. John". Later on, Nietzsche's views and social Darwinism (used to proclaim that helping the weak was against natural selection) were employed by the Nazi system to provide ideological underpinnings for the thesis of the superiority of Aryan races (Encyclopaedia Britannica, 1998) and the extermination of six million Jews.
Although the seeking of self-interest remains the basis of stigmatisation, the genetic origin of stigmatisation is not as deterministic as is sometimes implied. If genes can guarantee their own survival through encouraging the reproduction of people with similar or closely related genes, then how do we explain the high level of violence in families? Also, some people choose dangerous hobbies and pursuits for self-fulfilment purposes even if they might lose their lives in the process, which, of course, would not lead to any genetic interest. There is no evidence that the numbers of such people are reducing nor that the ultimate logic in having these dangerous hobbies is necessarily to attract the opposite gender and propagate one's genes. Also, there are people who choose not to have children, cutting back, in effect, the hope of their species' genes to self-replicate while they compete ardently on economic grounds, and there is no more reason to believe that they do so (unawares) for others to procreate on their behalf (like worker bees who sacrifice their fertility for the sake of their queen to procreate) than they do so on account of their own fulfilment.
Viruses, protozoa and even higher animals are highly restricted by the fiat of their genome and lack the human freedom for intervening intellectually, ideologically or scientifically in the workings of their own genes or gene products. Humans are relatively freed from the hegemony of genes and are offered, through evolution, more space, options and alternatives in choosing their own behaviour and destiny. This idea that evolution has an unrelenting tendency towards releasing higher species, especially humankind, from biological constraints is of pivotal significance for the reconstruction of a new discourse for modern evolution. It is ideology that decides how we are going to use our relative freedom from the biological imperatives that still restrict the animal kingdom. Ideology is not genetic and, even if it were proved to be, there would always be the possibility of choice between the countervailing ones.
In ideologically favourable societies, opting for non-stigmatising behaviours could have reproductive value. A change of culture may render ancient adaptive mechanisms irrelevant for survival in modern circumstances. Culture can design environments that would lead to the selection not of stigmatisers but of cooperative interdependent protagonists. Indeed, groups whose members cooperate with one another may out-produce groups composed of selfish individuals (Sober & Wilson, 1998). What hinders a more equitable approach to other humans can only be the vestiges, in our genome, of our animal evolutionary heritage, whereas deployment of our newly acquired evolutionary autonomy can help us to develop cultures that promote destigmatisation.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication March 29, 2000. Revision received June 26, 2000. Accepted for publication June 28, 2000.