Book Review

The Mark of Shame: Stigma of Mental Illness and an Agenda for Change

N Engl J Med 2007; 357:311-312July 19, 2007

Article

The Mark of Shame: Stigma of Mental Illness and an Agenda for Change
By Stephen P. Hinshaw. 331 pp. New York, Oxford University Press, 2007. $35. ISBN: 978-0-19-530844-0

Stephen Hinshaw's book will be of interest to readers well beyond the fields of psychology and psychiatry. He begins with a critical analysis of concepts and deftly summarizes the major schools of thought regarding what mental illness is, removing the comfort zone created by the hegemony of our academic departments, disciplines, and personal beliefs. He shows clearly that although many models of mental illness can help us understand various aspects of psychopathology and treatment, no extant model — nor, perhaps, any conceivable model — can fully explain what mental illness is or what it means.

The most exciting and engrossing part of this book is the detailed historical analysis of popular and medical thought regarding mental illness. Hinshaw analyzes how beliefs about mental illness held by medical practitioners and religious leaders in different parts of the world and at different points in history have influenced persons suffering from mental illnesses and have contributed to their stigmas. Since this is a historical account, only severe mental illnesses — severe depression and psychoses, including mania — are addressed. The more common and less severe mental illnesses generally were not recognized until the 20th century. Hinshaw points out some intriguing contradictions in the conception and treatment of mental illness; for example, the idea that treatments we would now describe as torture were used effectively to treat psychosis seems at odds with the belief that psychiatric illnesses have physical causes.

Institutionalization receives extensive attention in this book. It is easy for the reader to think about the rise and fall of institutionalization during the 20th century, but in fact, institutionalization has been waxing and waning throughout history. The influence of institutionalization on stigma has been profound. When institutions look like prisons and when patients are treated as though they are prisoners, the sense that people with mental illnesses are dangerous is reinforced. When entry fees are charged to the public to watch the antics of the patients, the sense of otherness, strangeness, and depravity is increased. It is little wonder that closing institutions and leaving the inhabitants to their own devices is frightening to the public at large.

Hinshaw discusses various approaches to fighting stigmas, including past successes and failures and the best hopes for future work. He includes some intriguing case studies, such as a stigma-reduction campaign in Canada that actually increased the stigma in the intervention town when rumors circulated that the researchers intended to build a large psychiatric facility in the vicinity. Hinshaw points out that facilitating contact with mentally ill persons has been successful in reducing stigma in some groups but not in others, and that although an emphasis on the biologic bases of many mental illnesses has decreased the belief among the public that people are to blame for their own illnesses, it has also left many with the feeling that mental illnesses are chronic, untreatable, and permanent. He calls for a balanced approach to public education, with an emphasis on the fact that mental illnesses are treatable, rather than a focus on their causes.

Hinshaw's intelligent and somewhat philosophical approach is powerful. He does not, however, address the issue of the glass ceiling in the fight against stigma. The ceiling will get higher as treatments improve, but because mental illness is disabling, it will always be there.

The content of this book is broad, deep, and fascinating. Hinshaw's father battled bipolar disorder, and I am sure that the experiences of his family have inflamed his sense of injustice and his desire to eliminate stigmas. Hinshaw's skill as a writer cannot be overstated. He uses a mixture of technical and lay language to paint a picture of stigma across the ages that is thoroughly enjoyable to read despite its often distressing content. In addition to being a professor of psychology, Hinshaw comes across as a passionate historian and humanitarian.

Claire M. Kelly, Ph.D.
University of Melbourne, Melbourne, VIC 3056, Australia
ckel@unimelb.edu.au