The Mark of Shame: Stigma of Mental Illness and an Agenda for Change By Stephen P. Hinshaw. Oxford University Press. 2007. 352pp. £19.99 (hb). ISBN 0195308441

Stephen Hinshaw has produced a very useful contribution to the debate on two particular issues: why do we stigmatise people with mental illness, and what should be done. He sets the scene by disclosing that his father had ‘lifelong, misdiagnosed bipolar disorder… the condition – and the stigma he experienced – took a major toll on him and the whole family’. So, although written from an academic point of view, Hinshaw really does know what he is talking about.

The book is understandably strongest on the psychological literature about stigma. For example, he writes with clarity and subtlety about attribution theory and the mixed evidence of whether using biochemical or genetic causal theories of mental illness in fact lead to lesser or greater stigmatisation. The book also goes further than previous accounts in a detailed discussion of both the perception of social risk which is generally held, and the existential risk that people with mental illness symbolise. He elaborates upon this using both an adapted version of terror management theory and a careful interpretation of concepts from evolutionary theory. Further particular strengths of the book include: the thorough reviews of relevant social psychological theories; a comprehensive summary of attempts to change public attitudes about mental illness; and a nuanced view of how stigma relates to children with mental illness, and to children of mentally ill parents.

This book needs to be seen in the context of a re-emerging scientific interest in the origins of stigma and in the roots of its destruction, with a recent suite of books strengthening the field. The reader finds less here on sociological theories that try to understand or guide action about stigma, for example what is called systemic or structural discrimination, and these issues are better dealt with in the recent book by Corrigan. ¹ Similarly, Hinshaw largely restricts his focus to stigma within an American context; the global picture is more fully covered by Sartorius & Schulze ² in their overview of the Word Psychiatric Association campaign against stigma. More practical aspects of social inclusion, such as employment, are addressed particularly well in the recent brief volume by Warner & Leff. ³

But I also need to declare an interest, a strong interest, in reviewing this book. Just months before the publication of Hinshaw's volume I also wrote a related book (on discrimination from the perspective of people with mental illness), for the same publisher! ⁴ With some hesitation I read The Mark of Shame to see whether our independent reviews were convergent or discordant. I am pleased to report, despite our different approaches to this literature, a high degree on interrater reliability in these two non-systematic reviews! Hinshaw and I both come to the view that stigma should be seen to include three related elements: a cognitive/information challenge (ignorance and the use of stereotypes); an affective challenge (prejudice); and a behavioural challenge (discrimination). In systematising our knowledge, especially of the first two of these domains, Hinshaw's new book brings greater clarity to our understanding of the processes active in stigmatisation and so strengthens our hand in going on to take the necessary action.