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Graham Thornicroft is a British psychiatrist with a long and distinguished career at the Maudsley NHS Trust and Institute of Psychiatry, London University. He is a well-respected researcher and has published extensively in the academic literature. He brings to this book several decades of experience and commitment to mental health care, but more particularly a concerned and sometimes angry and exasperated clinician's eye. This is not one more book talking about the social construction of stigma. Nor is it an out of hand condemnation of psychiatric services where most often people are truly trying their best to make a difference in an indifferent world. It is a cogent and provocative analysis of the ways in which discrimination, prejudice and stigma affect the lives of people with mental illness. At the heart of each chapter lies the person. And at the heart of each person lies a wound inflicted by something we can change.
Even before the text begins, as the book is first picked up, the reader is struck by the emotional impact of stigma and discrimination. The front cover shows a work by Jean Michel Basquiat in which hallucinatory and distorted faces, very reminiscent of examples of psychiatric art by psychotic clients, are capped by haloes; angels and devils in one. The inside cover first has a poster from an award-winning film Schizo, followed on the next page by a photograph of the British boxer Frank Bruno who famously suffered from severe depression and whose story made the front page of a newspaper under the headline Bonkers Bruno (or something like that). Before you start reading page one you are confronted with discrimination based on misinformation, misinterpretation and misanthropy.
The body of the text is divided into several chapters which detail the way in which discrimination, misunderstanding, misinformation and fear shows itself among families (my father just thought I was lazy), in obtaining housing (do I tell a landlord?), in close and intimate relationships (is having schizophrenia likely to get me more dates?), in employment (what do I say at an interview?), in health (should I tell an insurance company?) and the media.
Thornicroft then goes on to explode some of the myths and disinformation, that while perhaps common knowledge among professionals and interested bodies, still bear some repeating, such as the level of violence and levels of intelligence. He looks at some of the sources of stigma and considers the value of enforceable codes of practice for journalists, and although some of the references for media representation (film, television and print) may not be the most current, the force of the argument remains.
Importantly, he also considers the issue of self-stigmatization and anticipated discrimination. If I know that I am going to be rejected, why do I even try to begin with? This self-fulfilling prophecy seems to be an important step forward in developing a model of self-efficacy and self-determination in mental health services. In a genuine recovery model of care, strengths are the focus, not perceived weaknesses or limitations, and responsibility to act comes alongside the rights to do so.
Thornicroft outlines a number of areas for development and practical action. He provides examples and advocates for initiatives at local, national and international levels, and provides strong justifications for those actions that actually seem to make a difference to peoples' lives. He is not above a little advocacy and devotes some space to what he would like to see done, but the tone of the book, and especially the concluding chapters is one of pragmatic optimism. It is with good reason that the two final chapters are sub-titled, "Challenges for service users" and "Challenges for everyone". Things can change, peoples' lives can change.
While ignorance and misinformation, disinformation if you will, are important factors in the underlying causes of stigma, the answer to a fairer, less discriminatory world is not simply more education. Stigma is also fear based. Stigma is used to demarcate you from me. Stigma presents a challenge to professional groups. Stigma, in the end diminishes us all.
It is perhaps a cause for regret that such a book is still necessary. However, it is still required. The subject is still relevant. People are still suffering from stigma and discrimination. Mental illness is still greatly misrepresented and often misunderstood. Thornicroft has written one of the most important books on the subject of stigma and discrimination to emerge in the last few years. It is to be recommended to all those involved in mental health care, practitioners, students, advocates and consumers alike, and all who have a social conscience that may be ready to turn to action.
© 2008 Mark Welch
Mark Welch, British Columbia
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