Stigma is a pervasive issue in mental health and one that has deep historical and cultural roots. In this survey of the concept of stigma, psychology Professor Stephen P. Hinshaw draws together an extensive range of research and publication to provide a comprehensive review of stigma of mental illness, and to propose a program for change. Mindful of the entrenched nature of stigma, and of the sometimes paradoxical results of previous efforts to improve acceptance of mental illness, Hinshaw adopts a measured approach. While urging programs of applied research, public education, and improved services, he is aware that none of these attempts at change can succeed individually, and that each is dependent on various lay and professional interest groups playing a part. The Mark of Shame is impressive in its range and depth of coverage, and should provide a valuable resource to all those concerned with this important issue.

Hinshaw is well placed from both personal and professional perspectives to address the stigma surrounding mental illness. Amongst his many publications is an account of his father's life with bipolar disorder, something that is also discussed in the present work. Virgil Hinshaw was a philosopher, and an accomplished academic. He suffered from a belatedly diagnosed mental disorder, something he kept secret from his son until the latter's early adulthood. Hinshaw includes excerpts from his biography of his father, and discusses his own responses to learning that mental illness had affected his own upbringing and family. Hinshaw's research interests are to do with developmental psychopathology, especially Attention Deficit Hyperactivity Disorder (ADHD). He has held numerous research grants in this area, and has published extensively. His interest in ADHD is apparent in The Mark of Shame; many of the chapters include specific sections on issues relating to children.        

The book is structured into three main sections. The first covers definitions of stigma and mental disorder, theoretical approaches to stigma and an historical overview of mental illness and stigma. The middle section reviews current conceptions of mental disorder, research into stigma and social manifestations of stigma. The section ends with a chapter integrating this diverse literature. The final section addresses the subtitle of the book, Hinshaw's agenda for change. This section discusses research priorities, and devotes three separate chapters to different aspects of the agenda for change, followed by a concluding summary.   

The first chapter of the book begins with a selection of case studies of individuals with mental illness. These provide a basis for outlines of models of mental illness and a conceptual framework for considering stigma. Most of the material in the section on models of mental illness is familiar, but the section is nevertheless a useful summary of different, often conflicting models. It also helps to provide a context within which to read the rest of the book, especially in terms of Hinshaw's commitments to the various models. Hinshaw is more optimistic than some commentators on the possibilities of neuroscience. He gives due recognition to theoretical work by writers such as Jerome Wakefield, even if he is in disagreement with Wakefield's views. In summarizing stigma and related concepts Hinshaw draws on the work of Erving Goffman, and more recent work linking stigma to social power. The following chapter considers stigma in more detail, reviewing a range of theoretical approaches, and greatly expanding the notion of stigma beyond that of an individual or institutional attitude. One of the most provocative and interesting parts of this chapter is Hinshaw's exploration of an evolutionary model of stigma, something that might explain the pervasiveness and persistence of stigma. Brief histories of mental illness are almost always problematic both methodologically and theoretically, and Hinshaw's summary is no exception. There is no doubt that historically groups of people seen as different have been socially disvalued and marginalized, and that those with what we now conceptualize as mental illness are amongst those groups. But I did find this section of Hinshaw's book less critical than others. Witchrcaft is discussed as an example of stigmatization of the mentally ill, yet there is a vast scholarship on this topic that would question such a simplistic view. Other observations are made without reference to primary sources, such as the claim that during the 16^th century more than 30% of the population of Paris were beggars. This is an extraordinary figure that at least deserves a citation. The review of history contains no reference to the work of Scull, which also seems an important omission, and one that would certainly support an argument that stigma played a part in the rush towards institutionalization in the 19^th century. Hinshaw notes the waxing and waning of attitudes to the mentally ill throughout history, and the basis of views of mental illness in 'general cultural worldviews'. His conclusion is the modernist suggestion that science is likely to provide more informed views and hence less stigmatization of the mentally ill.      

The middle section contains of the meat of this book. The chapter on modern conceptions of mental illness reviews evidence on genetics and the neurobiological evidence on mental disorder, but cautions that a reductionist interpretation of this evidence is potentially dehumanizing. Notwithstanding an acceptance of neurobiological evidence, Hinshaw argues for an interpretation that emphasizes common humanity, not difference. The focus of the book then shifts to consideration of research on stigma. Different areas of research from the 1940s onwards are reviewed, with the notable finding that greater understanding of the medical view of mental illness does not automatically lead to greater acceptance of individuals with mental illness. This will be a sobering reminder to some that stigma related to mental illness is deeply ingrained. Hinshaw suggests that current trends to destigmatise mental illness as 'brain disease' may be counter productive, as they may contribute to beliefs in chronicity, helplessness and genetic inferiority. Hinshaw next considers the everyday manifestations of stigma. While again the news can hardly be considered good, the discussion of the potential for individual and family narratives to lead to increased understanding provides some basis for optimism, something Hinshaw acknowledges with due caution. An integrative chapter explores the viability of the concept of stigma, drawing together psychological and sociological theories leading, in the following chapter to suggestions for how different aspects of stigma may be approached through research. This chapter explores the link between stigma and discrimination, a link of great theoretical and practical significance. The discussion of stigma is extended to include mental health professionals, families, and the mentally ill themselves who might perpetuate stigma through internalization.

The following three chapters explore different programs of intervention. These include possibilities for legislation, public policy, practices of the media and mental health professionals, and strategies for families. Together these chapters illustrate the complexity of stigma, and the need to conceptualize on multiple levels. Some suggestions such as greater status for mental health professionals in comparison with their general health colleagues seem to defy attempts to change. Others, such as working with media to achieve more sympathetic reporting have been demonstrated to work, and may in turn reduce the 'courtesy stigma' experienced by mental health professionals. Perhaps provocatively, Hinshaw suggests that the mentally ill have a part to play by cooperating with professionals' attempts to provide mental health care, and so ameliorate the outward signs and behaviors that contribute to stigmatization. Hinshaw is well aware that such a suggestion is controversial, and has the potential to be seen as 'blaming the victim'. But is hard to argue, at least in principle, with the idea that rights of citizenship confer reciprocal responsibilities. The question is, of course, where to draw the line, and Hinshaw is equally well aware that there is no straightforward solution to this ethical issue.

After such a comprehensive analysis of stigma, conclusions are necessarily cautious. However there are some points on which Hinshaw is unequivocal. Mental illness affects many more people than is commonly realized, and can be severely disabling. Mental illness is almost inevitably attended by stigma, something that is not an inherent aspect of mental illness, yet which contributes greatly to the degree of disability. Stigma is not just a problem for individuals, but is a problem for society, both in terms of any aspirations towards tolerance and pluralism, and in terms of reduced productivity. There are new challenges that must be faced if stigma is to be overcome, and in concluding Hinshaw recalls that optimism must be tempered with realism, especially in making promises about reducing mental illness and overcoming its effects. Experience has shown that failure to deliver on promises is likely to lead to retrenchment into stigmatized views.

I was a little surprised that there was no reference to the work of Patricia Deegan, and especially into the idea of 'recovery' and its focus on hope. Recovery, although by no means free of definitional and empirical problems, does offer the promise of an alternative paradigm of mental distress, and it may be this sort of paradigm shift that is required, rather than greater understanding of the current dominant medical model of mental illness. Recovery offers an alternative discourse of mental distress and explicitly challenges stigma. Of course a broad based model such as recovery still requires the sort of research and policy support Hinshaw advocates for in this book. In general, Hinshaw offers limited critique of the DSM based model of mental illness, although he does mention the need for greater understanding of dimensions, rather than categories of mental illness. While he is aware that over reliance on biomedical explanatory models can reinforce, rather than reduce stigma, he stops short of proposing an alternative model.  

Despite the reservations noted The Mark of Shame has more than enough to commend it. The book is a comprehensive and meticulously researched coverage of stigma. The writing is accessible and clear, and concepts are well explained. The content is logically organized with the early chapters providing a broad background against which to discuss the evidence and arguments about stigma. There are many pages of helpful footnotes, extensive referencing, and a useful alphabetical index. These features make The Mark of Shame an ideal academic reference work.  

   I leave the final word to Hinshaw, who in his final paragraph states:

"The ultimate question regarding stigma may well be whether we a society and a species are content to keep in place attitudes and policies that allow such a shocking waste of human talent and potential. The ultimate irony of stigmatization and discrimination is that all of society and all of humanity lose when these practices are perpetuated."

© 2007 Tony O'Brien

Tony O'Brien RN, MPhil, Senior Lecturer, Mental Health Nursing, University of Auckland, a.obrien@auckland.ac.nz

Categories: Ethics, MentalHealth