Book Review

Stigma and Mental Illness

N Engl J Med 1993; 328:1133April 15, 1993

Article

Stigma and Mental Illness
Edited by Paul Jay Fink and Allan Tasman. 236 pp. Washington, D.C., American Psychiatric Press, 1992. $35. ISBN: 0-88048-405-5

Although the inspiration for this thoughtful book came from the theme of the American Psychiatric Association's 1989 annual meeting -- “Overcoming Stigma” -- it moves well beyond those presentations to include important new material on the issue of stigma and mental illness. Paul Fink has led the crusade to destigmatize mental illness, and working with Allan Tasman, he continues his mission with this book. The book begins with statements by a family member, a psychiatric resident, and a patient, all of whom have been touched by mental illness. It then traces the stigma of mental illness from ancient Greece through medieval and Renaissance times, to the establishment of the asylum, and finally to “Madness and the Stigma of Sin in American Christianity.” Stigma and mental illness appear to be not only ubiquitous but also perniciously joined from the beginning of recorded history.

The book then delves into social issues with regard to stigma: homeless mentally ill persons, the contribution of cinematic stereotypes to the stigmatization of psychiatrists, the stigmatized family, and the need to help the physician's family when there is mental illness in the doctor or in a family member. This important material attempts to banish some of our most common myths. It also underscores the preservation of stigma by the media, in the portrayal of the homeless and the mentally ill patient as often violent and in the stereotype of the psychiatrist as “zany” and self-serving. These attitudes need to be confronted by the psychiatric profession and others. Lay groups such as the National Alliance for the Mentally Ill are attempting to counteract these “fixed ideas.”

Next, the book describes institutional issues related to mental illness and stigma as they regard medical students and residents, deinstitutionalized patients, the psychiatric hospital, electroconvulsive therapy, and finally, the stigmatization of psychiatrists who work with chronically ill persons. In all these chapters concrete suggestions are given to minimize attitudes that trammel patients and their families and prevent them from seeking badly needed care.

Stigma and Mental Illness succeeds in exposing the enmeshed connection between stigma and mental illness., and it shows how pervasive the stigma is in the attenuation of insurance benefits, the need to hide one's illness in order to obtain a driver's license or admission to a professional school, the custom of letting patients out the back door of the psychiatrist's office so that others will not see them, and the need to “earn” one's way out of a mental ward by matching expected behavior. Not so long ago, a vice-presidential candidate was asked to withdraw from the race because he had had a major depression requiring electroconvulsive therapy. He was not asked to withdraw because of incompetence or lack of character. Destigmatization requires demystification, the diminution of fears, and the end of the attribution of misunderstood behavior to demons and sin.

This book seeks to weaken the link between mental illness and stigmatization and provides concrete suggestions for health care and society. Stigma and Mental Illness is a unique education for all health care professionals: students, residents, and their teachers. It is comprehensive, authoritative, well reasoned, compelling, theoretically sound, and clinically relevant.

James J. Strain, M.D.
Mount Sinai Medical Center, New York, NY 10029