Revisiting Stigma: The Game of Appearances - Case Example

Saturday, June 15, 2024

Primary Blog/clinical issues/Revisiting Stigma: The Game of Appearances - Case Example

In the session from which the following excerpt is taken, Sam (patient) sees through his own act and the lengths he’d gone to present a certain façade, the “games” (as he referred to them) he played for desirability. He talks about where and how he learned to play these games, how he really felt inside and how difficult it is to not play them.

At the time of this dialogue, Sam had returned to treatment after a one year absence and having maintained sobriety for a year.

Sam (S): I didn’t want to come today. I’ve been doing real well. My day was going fine until an hour or so ago and I’m thinking, “I don’t need this.” I feel so uncomfortable. Why am I doing this to myself?

Daniel(D): Why did you come in?

S: It was when I ran into you at the supermarket.
D: That was quite a while ago.

S: I told you that I wanted to return only because I thought I should. I said what I thought you wanted to hear.

D: Say what I wanted to hear?

S: Yeah. Like when you ask me how I’m doing, I say want to come back cause that’s what I’m supposed to say.

D: Are you saying that you called me to fulfill a lie?

S: If I didn’t call, I’d look bad.
D: How you appear is a primary motivation… You look you have more to say.

S: One of the main fears I have about coming here is that I’m going to have that blank look on my face and I won’t know what to do, or say. I hate that look. A part of me wants to be a good client and be more comfortable talking about myself.
D: You put a lot of pressure on yourself.

S: I’m always trying to impress everyone. I want to be up there with the good guys.

D: What are you aware of right now?

S: Tension. Anxiety.

D: That happens when you feel that you must hide what you really feel inside.

S: I always make things up. At work, I always say that I made more sales than I really did. Stuff to look good. Stupid games. Stupid lies are what they are. It’s a habit. (pause) I’m really nervous. My hands are wet with sweat…I’ve got that blank look on my face, don’t I?

D: You must feel quite awkward when you’re not busy impressing people.
S: I don’t know what is supposed to happen here.
D: Especially when you’re unsure how to impress me. If only you knew how to be a good client… How long have you been trying to impress people?

S: It started with my parents. I know that.

D: They encouraged you to present a more together front.
S: I always made sure I got good grades.
D: You got stroked for being a “good” boy, while you kept other parts of yourself hidden.

S: (blank expression)

D: You have that blank look on your face.

S: I drifted off.
D: What’s the last thing you remember me saying?

S: I can’t remember.

D: I was saying that the better you played the game, the more praise you got, but the worse you felt.

S: I remember they (parents) always saying that I was better and smarter than my friends.

D: Do you remember you that made you feel?

S: I lied. I made up stuff about them, trying to get my parents to like them more… I don’t know whether I want to open a can of worms.

D: My sense is that you feel insecure when you aren’t hiding behind your game. Not playing is unfamiliar, overwhelming.

S: There are days when I get up in the morning and pray that I get through the day without doing it. And before I know it, I’m doing it.

D: Like the game is running you.

S: It scares me.

The process of therapy was paradoxical for Sam. When the light got turned on and he saw through his “game, he got terrified. The closer he got to real feelings, the more insecure and lost he felt, like he was a fish out of water. He was more “at home” in a defense mode than when feeling his feelings. Therapy was like a roller coaster ride, approaching, then avoiding feelings.

Sam is probably one of many who live their lives dreading this “ultimate” confrontation, facing their real feelings. All the while, they’re living jaded existences, banking on the illusion of normalcy and desirability. All the while, thinking, “Not know. Later. I’ll deal with it tomorrow” as if they could borrow time and postpone indefinitely the end of their game.

Where There is Stigma, There is Internalized Shame

In his book, Shame, The Power of Caring, Gershen Kaufman focuses on the experience of shame. He contends that shame is the most unbearable feeling known to humankind. That shame can contaminate a person’s whole identity and how one feels about oneself. Shame becomes internalized. The number and intensity of shame inducing experiences determines the extent to which personality develops as a defense against the feeling of shame. Self-talk and belief systems are variations on the same theme: self-degradation. “I’m a failure.” I’m a loser.” “I’m not good enough.” “I’m not lovable.” “The moment I open up and let myself be known, it’s the end of the relationship. The person will surely leave. Kaufman’s work attests to the power of stigma, it’s potential to dictate how we act in our relationships, because stigma induces shame.

In the case of addiction and other invisible conditions, stigmatization takes effect the moment the condition becomes known. The depth of pain and shame associated with stigma require the development of psychological defenses that counteract it. The huge stigma that addiction still carries (despite being deemed a disease) acts as a powerful incentive that bolsters the addict’s defense system. And, it is not just the addict we’re talking about, it is the significant others and everyone else involved who relies on denial. As long as s/he doesn’t expose his/her addiction to anyone, let alone, realize there is a problem, s/he’ll remain insulated from the intense shame and alienation that would otherwise be triggered.

Night, Mother: Stigma and Suicide

Excerpts of dialogue taken from the play, Night, Mother by Marsha Norman serve as dramatic examples of how the stigma attached to a disease (epilepsy) affects the relationships and communication within a family. The story revolves around a mother’s efforts to stop her daughter from committing suicide. The last scene is the sound of a gun shot.

Mama (M): I think your daddy had fits, too. I think he sat in His chair and had little fits. I read this a long time ago in a magazine, how little fits go, just little blackouts where maybe their eyes don’t even close and people just call them “thinking spells.”

The magazine said that some people don’t even know they’ve had one.

Jessie (J): Daddy would have known if he had fits, Mama.

M: Jessie, listen to what I’m telling you. This lady had anywhere between five and five hundred fits a day and they lasted maybe fifteen seconds a piece, so that out her life, she’d only lost two weeks altogether.

J: You want to talk about fits, is that it?

It’s apparent in the above dialogue that Mama’s display of ignorance -- referring to seizures as fits only further perpetuated that stigma attached to the disease of epilepsy. The stigma is directly related to the convulsions or seizures that can be frequent occurrences, and which can also be unwholesome, sometimes frightening sights. Epileptic seizures became known as “fits,” which are sudden, violent access of some specified emotion,” synonymous with “tantrums.” Referring to them as fits implied a mental and emotional imbalance, which carries an even greater stigma than an epileptic seizure, convulsion or neurological disorder. When seizures became known as fits, a derogatory term is used in daily discourse as a source of metaphor and imagery without giving thought to the original meaning, and a wide range of imperfections was imputed to the original one. (Goffman)

It’s also apparent that Mama was also trying to minimize the fact that Jessie was subjected to seizures, which obviously added weight to the burden of shame Jessie had already internalized. While Mama was clearly trying to make Jessie feel better, she was clearly failing miserably. First she suggests that you’re barely aware that anything is awry by referring to them as “thinking spells.” Again she tries to minimize them by implying that they are so frequent, yet short-lasting, they’re incidental and hardly matter. Mama was inadvertently making a bad situation worse, bringing more attention to the stigma in her effort to deny it.

The next section captures horrific images conjured up and consistent with how one of Jesse’s seizures were seen through the eyes of another, her mother.

J: Most of the time I wouldn’t know I’d had one, except when I wake up in the morning with different clothes on, feeling like I’d been run over.
M: I can tell when you’re about to have one. Your eyes get this big!

J: (Taking charge of this) What do they look like, the seizures?

M: (Reluctant) Different each time, Jess.
J: O.K. Pick one, then. A good one. I think I want to know now.

M: There’s not much to tell. You just…crumble, in a heap, like a puppet and somebody cut the strings all at once, or like the firing squad in some Mexican movie, you just slide down the wall you know. You don’t know what happens? How could you not know what happens?

J: I’m busy.

M: That’s not funny.

J: I’m not laughing. My head turns around and I fall down and then what?

M: Well, your chest squeezes in and out, and you sound like you’re gagging, sucking air in and out like you can’t breathe.
J: Do it for me. Make the sound for me.

M: I will not. It’s awful sounding.

J: Yeah. What’s next?

M: Your mouth bites down and I have to get your tongue out of the way fast, so you don’t bite yourself.
J: Or you. I bite you, too, don’t I?

M: You got me once real good. I had to get a tetanus shot. And then you start to turn blue and the jerks start up.
J: Foaming like a mad dog the whole time.
M: It’s bubbling, Jess, not foam like the washer overflowed, or, for god’s sake it’s bubbling like a baby spitting up. I go to get a wet washcloth, that’s all. And the jerks slow down and you wet yourself and its over. Two minutes tops.

J: How do I get to bed?

M: How do you think?

J: I’m too heavy for you now. How do you do it?

M: I call Dawson. But I get you cleaned up before he gets here and I make him leave before you get up.

J: You could just leave me on the floor.
M: I want you to wake up some place nice, O.K?

We see that Jesse establishes that she is well aware of the truth, the horrible truth. She gets her mother to describe the unspeakable. Mama is temporarily freed up from the shackles of denial, able to provide graphic details. However, we can see that she is still trying to protect Jesse by making the fits sound entertaining, like cartoons, which have the effect of bringing more attention to something being wrong or shameful about Jesse’s condition.

When Mama depicts herself as attentive by going to such great lengths in her care taking of Jesse, we can see that she is inadvertently perpetuating the secret. And in so doing, Jesse confirms for herself. That she was always treated as if there was indeed something inherently shameful about her fits, as they had to be kept secret.

In the following scene, Mama is trying to convince Jesse that there is reason to live. But ironically, her explanation for Jesse’s fits and accounting for how she handled her having epilepsy seals Jesse’s fate. Suffice it to say that Mama’s efforts to avert Jesse’s suicide were unsuccessful. It becomes clearly apparent that Mama’s misrepresentation and outright deception served to further reinforce internalized shame and alienation that begun when Jesse was a child.

M: The fits are over!

J: It’s not the fits, Mama.

M: Then it’s me for giving them to you, but I didn’t do it! Your daddy gave you those fits, Jesse. He passed them down to you like your green eyes and your straight hair. It’s not my fault!

J: So what if he had little fits? It’s not inherited. I fell off of a horse. It was an accident.
M: The horse wasn’t the first time, Jesse. You had a fit when you were five years old.

J: I did not.

M: You were eating a popsicle and down you went. He gave it to you. It’s his fault, not mine.

J: Well, you took your time telling me.

M: How do you tell that to a five year old?

J: What did the doctor say?

M: He said kid have them all of the time. He said there wasn’t anything to do but wait for another one.

J: But I didn’t have another one… You mean to tell me I had fits all the time as a kid and you told me I fell down or something and it wasn’t until I had the fit when Cecil was looking that anyone bothered to find out what was wrong with me?

M: It wasn’t all the time, Jesse. They changed when you started school.

J: How many fits did I have?

M: You never hurt yourself. I never let you out of my sight. I caught you every time.
J: But you tell anybody.

M: It was none of their business.

J: You were ashamed.

M: I didn’t want anyone to know, least of all you.

J: Least of all me. Oh right, that was mine to know Mama, not yours. Did Daddy know?

M: He thought… you fell down a lot. That’s what he thought. You were careless. Or maybe he thought I beat you. I don’t know what he thought. He didn’t think about it.

J: Because you didn’t tell him

M: If I told him about you, I’d have to tell him about him.

J: I don’t like this. I don’t like this one bit.

M: I didn’t think you’d like this. That’s why I didn’t tell you

J: If he knew I was epileptic, Mama, I wouldn’t have ridden any horses.
M: Make you feel like a freak, is that what I should have done? Maybe I did drop you, you don’t know. Maybe I fed you the wrong thing. Maybe you had a fever some time and I didn’t know soon enough. Maybe it’s a punishment.

J: For what?

M: I don’t know. Because of how I felt about your father. Because I didn’t want anymore children. Because I smoked too much or didn’t eat right when I was carrying you. It had to be something I did.
J: It does not. It’s just a sickness, not a curse. Epilepsy doesn’t mean anything. It just is.

It seemed that everything Mama had said to explain her actions only exacerbated the situation and confirmed all of Jesse’s suspicions. First she blames Jesse’s father, as if he was responsible, and not her, for the horrible crime of causing Jesse’s epilepsy. Then we become privy to the cause Jesse’s confusion about whether or not epilepsy is inherited as she was lied to all along, having been told that it was the result of an accident, i.e. falling off of a horse. Mama defended herself by telling Jesse that she was too young to understand.

When Mama admits to having deliberately concealed that information from Jesse since age 5, she makes matters worse by revealing that she never bothered to find out what the problem was, never consulting with a doctor for a diagnosis until Cecil witnessed a seizure. In fact, Mama reveals that she never told anyone, “It was no one’s business.”

What would it have meant if someone found out Jesse had epilepsy? Mama saw herself as loyal and protective for having concealed the problem, “Make you feel like a freak. Is that what I should have done?” The most telling implication in Mama’s portrayal of herself as an ally was going as far as hiding the existence of the disorder from her husband, Jesse’s father, for he, too, was epileptic. In her mind, she was protecting him from the onslaught of shame that would have come crashing down on him the moment the stigmatized condition was exposed. Mama’s need to keep the stigma secret took precedence over what her father knew or thought about his daughter’s well-being. No matter whether he thought Jesse’s “falling down a lot” was due to poor parenting, even abuse would have been easier to deal with than epilepsy. Mama went as far as risking Jesse’s safety by allowing her to ride horses rather than letting anyone find out, including Jesse.

As a result of Mama’s aversion to pursuing this matter further and accounting for Jesse’s strange, “undesirable|” behavior by seeking professional consultation, no one in her family ever found out what was actually wrong; that her seizures were due to a neurological disorder called epilepsy, and that epilepsy is treatable!

Mama was operating as if she could protect her family from their own humanness. Her dogged persistence attests to the extent to which the stigma and associated shame were, both internalized and intolerable. Furthermore, it becomes apparent that she felt responsible for Jesse’s epilepsy, that she must have fallen short in some way and which caused it. It appears that she never understands that epilepsy “just is.” This was probably one of her limitations for she was a product of the familial and social conditioning of her time. She was taught to crucify herself for being vulnerable to one of nature’s aberrations (epilepsy), one she didn’t choose or could will away.

​Despite her loneliness and desperation, Jesse was still able to articulate that epilepsy “just is,” that a disease is a sickness, not a curse. Whether you judge it, wish it away, try to hide it, attribute it to other causes, or feel ashamed, it is what it is, a disease.

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Hi, Daniel

Daniel A. Linder is a licensed Marriage & Family Therapist, Relationship Therapist and Trainer, an Addiction and Intervention specialist, with nearly four decades of experience working with individuals, couples and families.

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