In the preface to Asylums, Canadian sociologist Erving Goffman offers a method to understand the social world of the mental hospital inmate — her world as she experiences it. Instead of employing common measurement methods, such as statistical evidence, Goffman gathers data on 'the tissue and fabric of patient life' by observing patients' daily lives in the hospital (Goffman 1961, X). He excuses the statistical limitations of his investigation by suggesting that he wants to portray patients' situations 'faithfully', to balance this account against the professional literature, which is primarily written from the point of view of the psychiatrist. Others besides Goffman have noticed this imbalance in the mental health literature, and in the past two decades, a number of first-person narratives have been produced by persons with mental illness. Stephen Hinshaw's Breaking the Silence makes a unique contribution to this body of work.

What makes Hinshaw's work unique is not simply the portrayal of the experiences of people with mental illness. Rather, the story-tellers are mental health professionals who either have a mental illness or come from a family with a history of mental illness. Bringing together a collection of such disclosures, Hinshaw aims to bridge the 'us vs. them' gap between mental health professionals and patients. In his view, if we hear stories of mental illness told by mental health professionals themselves, or their families, we may understand how pervasive mental illness is, and we may be forced to abandon the stigmas currently attached to it.

Each narrative in the book tells us how the experience of mental illness has impacted the narrator's personal and social experiences, how it has shaped her identity or influenced her career choices. We read about the narrators' emotional pain, their courage dealing with a non-linear process of recovery, and their ambivalence about treatment methods, such as the use of medication. These stories are descriptive, showing us how diverse the symptoms of a particular mental illness may be, but noting family resemblances between illnesses. They are also critical, in that they provide a range of criticisms about the process of psychiatric diagnosis, the lack of social and institutional support for people dealing with mental illness, the insensitivity of mental health professionals, and the unresponsiveness of society.

The book is appealing in its ability to flesh out and humanize the notion of 'stigma,' notably, by showing how the individual writers confronted stigma in their daily lives. Theodore P. Beauchaine's 'Memories of Parental Decompensation' shows that his mother's experience with schizophrenia had a deep emotional impact on him and his siblings and influenced his later career choices. Despite the importance of his personal experience on his choice to become a clinical psychologist, he was encouraged by a professor to avoid sharing insight this in his personal statement when applying to graduate school. His professor argued that the faculty members on the admissions committee would want to ensure that the admitted graduate students were capable of personal detachment; they might fear that his intimate experiences with mental illness would cast a shadow on his academic performance. This rich example shows how even the professionals in the field tend to stigmatize the illness, albeit acting under a professional code of silence.

The book also traces the evolution of treatment methods. In 'He Just Can't Help It: My struggle with my father's struggle with bipolar disorder,' psychologist Esme A. Londahl-Shaller talks about her father. We read about his psychiatric treatments and hospitalizations at a time when insulin and electroshock, lobotomies and hydrotherapy were commonplace in American state hospitals. Her father makes an interesting comment on labeling: he notes that the label of mental illness follows an individual throughout his entire life — once people know someone has BPD, they think everything this person does is due to BPD (Hinshaw, 276).

Written by Tara Peris, a postdoctoral fellow at UCLA, the third narrative, 'A Field Agent in Our Midst,' gives us an account of the author's life with a schizophrenic mother. She gives us an honest account of her struggle accepting her mother's condition. She acknowledges the reverberations of her mother's disease throughout her life, and she confesses her reluctance to write this narrative.

The fifth narrative, 'In My Voice: Speaking out About Mental Health and Stigma,' by Jeff Liew, an assistant professor of education, illuminates his family's struggle with his mother's depression, as well as the difficulties of being an immigrant family in the US. This narrative relates mental illness to socio-economic circumstances, pointing out, for example, the communication problems which arise between the therapist and the patient due to linguistic barriers.

In 'Colombus Day, 1994: A new world,' Kay S. Browne, a behavioural pediatrician, tells us about her son's mental illness, her frustration with his medical treatment process, and the prevalent pessimism amongst mental health professionals about recovery and healing. She makes a striking point about the side-effects of heavy medication. The overwhelming experience of mental illness combined with the neurological and metabolic side-effects of medication, in her view, can create a person who looks mentally ill, which contributes to the social burden of the individual and the family members (Hinshaw, 172)

In 'The Meaning of Mental Health (and other lessons learned)' Marc S. Atkins, professor of psychology and psychiatry, talks about his auditory hallucinations during the era of the Vietnam war, and the psychiatric treatment he received afterwards. Defining his goal in writing this piece as bridging worlds and perspectives between his own personal experiences with mental disturbance and his clinical expertise, he calls himself therapist, patient, neither, and both. He tells us how his psychiatrist told him he had schizophrenia, saying it was genetic and he would never fully recover, impressing on him the need to receive treatment and to start taking anti-psychotic medication. His experience with medication, however, made his thinking more incoherent. Only after he returned to school did he start to recover — notably by learning to channel his thoughts by writing about them. In retrospect, he suggests that even though some of the vulnerabilities associated with his disturbance remain with him, he has learned how to deal with them. In other words, his first doctor's remarks about the unavoidability of serious mental health disturbance were not true, at least in his case. Reading his account made me wonder if a purely medical explanation of mental illness (even though the diagnostic categories are devoid of serious etiological information) may present an obstacle to recovery by limiting the patient's responses to the condition.

In 'The Game With No Rules: A sibling confronts mental illness,' Jessie Borelli describes her brother's chronic struggles with aggressive behavior, shut-down moods, and a range of psychiatric diagnoses, including severe ADHD and bipolar disorder. She talks about her brother's diagnosis with ADHD at the age of six and his subsequent medication. Even though she is ambivalent about the decision to begin medication treatment, she portrays honestly how families search for a 'cure,' and she stands behind her family's choice of medication for her brother, for better or for worse.

In the last chapter, 'The Legacy of Loss: depression as a family affair' by Carolyn-Zahn Waxler, we read about her mother's depression and her father's drinking as a coping mechanism. She emphasizes how sensitivities and vulnerabilities are heightened by encountering mental illness, but she notes that illness also opens up unique possibilities and offers life-affirming transformations.

An interesting trend in some narratives was the suggestion that mental illness could be considered as having purely biological or genetic roots, thereby avoiding the stigma attached to it; if mental illness is biological, the disturbing behaviors of people with such an illness are not volitional. In 'Memories of Parental Decompensation,' Theodore Beauchaine narrates his mother's schizophrenia and his father's struggle with alcohol. At the end of his piece, he points out how in many western societies, behavior associated with mental illness, such as substance dependence, melancholia, homelessness, and lack of motivation, are considered to be volitional, and this results in the marginalization of people with psychopathology. This is rarely observed for physical illnesses where affected individuals are perceived as victims. Beauchaine hopes mental disorders will one day be accepted in the way that most physical illnesses are now accepted. He wants them to be seen as arising from brain dysfunctions — we should not blame people with mental illness for their actions.

Undoubtedly, mental illness has a biological dimension. Even so, the purely genetic and biological models of explanation and the desire to excuse patients' behavior based on its non-volitionality can be stigmatizing because they depict people with psychopathology as abnormal at the core. Proposals like Beauchaine's may come from an innocent desire to cure mental illness and a belief that if it is measurable, calculable, and filmable, it can be controlled. This belief, however, can undermine the agency of people with mental illness by deeming their actions purely non-volitional. Some of their behavior may not be in their control, but we cannot treat them as automatons being controlled by their inner biological machinery.

Hinshaw's interesting and valuable collection of narratives will appeal to a variety of audiences, including academics who are interested in understanding the phenomenology of mental illness, its treatment, and its socio-institutional administration, government officials developing health care policy, and people who live close to mental illness.

© 2009 Serife Tekin

Serife Tekin is a PhD Candidate in the Department of Philosophy, York University, Toronto,

Keywords: stigma, disclosure