THE MARK OF SHAME This page intentionally left blank THE MARK OF SHAME Stigma of Mental Illness and an Agenda for Change Stephen P. Hinshaw 1 2007 1 Oxford University Press,Inc.,publishes works that further Oxford University’s objective of excellence in research,scholarship,and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Copyright © 2007 by Stephen P.Hinshaw Published by Oxford University Press,Inc. 198 Madison Avenue,New York,New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved.No part of this publication may be reproduced, stored in a retrieval system,or transmitted,in any form or by any means, electronic,mechanical,photocopying,recording,or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Hinshaw,Stephen P. The mark of shame : stigma of mental illness and an agenda for change / Stephen P.Hinshaw. p.cm. Includes bibliographical references. ISBN-13 978-0-19-530844-0 ISBN 0-19-530844-1 1. Mental illness—Social aspects. 2. Mental illness—Public opinion. 3. Stigma (Social psychology). I. Title. RC455.2.P83H56 2006 616.89—dc22 2006019106 9 8 7 6 5 4 3 2 1 Printed in the United States of America on acid-free paper Acknowledgments Writing a book of this sort is a labor of love. Throughout my work, I have learned a wide array of concepts,I have read diverse scientific literatures,and I have scoured references from works of history to articles in current magazines and newspapers.Without support,I couldn’t have done it. Dante Cicchetti encouraged me to contribute an article on stigma and men- tal illness for a special issue of his journal,Development and Psychopathol- ogy,a number of years ago.At that time he knew of the writing I was doing on my father’s lifelong mental illness and of my growing interest in the shame and silence that too often accompany mental disorders.After we wrote that article together,both Dante and Sheree Toth were to have been my coauthors for this book.Yet my own momentum on the project and their increasing involvement in numerous other activities prevented this collaboration from coming to fruition. Still,several of the vignettes about children in these pages emanate from them,as do some of the key thoughts about resilience and developmental issues.I thank them heartily for their efforts and support. Anumber of people who study stigma have been instrumental in guiding my ideas. I express my deep admiration for these pioneers: Patrick Corrigan, Jennifer Crocker,John Dovidio,Amerigo Farina,Susan Fiske,Samuel Gaertner, Erving Goffman,Nick Haslam,Bruce Link,Brenda Major,David Penn,Jo Phe- lan, Norman Sartorius, Otto Wahl, and many others. I have ridden on their shoulders; the next generation of scholars and activists owes them a major debt of gratitude. For careful and thoughtful reading of chapter drafts,I express my great ap- preciation to Andrea Stier and Rudy Mendoza-Denton, whose critiques were sharp and insightful. For perceptive comments on selected chapters, I thank David Donovan,Joelle LeMoult,and Lynn O’Connor.For ideas,encouragement, vi Acknowledgments and general support,I express my appreciation to Mario Aceves,Brian Bohn, Jessica Borelli,Whitney Brechwald,John Guerry,and Liz Owens.Two anony- mous reviewers made cogent comments on a penultimate draft. For mentor- ship when I was an intern at UCLA’s Neuropsychiatric Institute,as well as sen- sitization to issues related to stigma,I deeply thank Kay Redfield Jamison.For masterful editorial assistance,I express my appreciation to Catherine Fan. My editor at Oxford University Press, Catharine Carlin, has been entirely encouraging from the moment we discussed the possibility of this book.As any writer knows, such support and encouragement are essential during the many times that the author begins to wonder whether things will ever really come together.She has a keen eye and ear for conveying essential messages. In many ways, a book like this has been a lifetime in the planning. If it weren’t for the experiences in which I grew up,including my father’s lifelong mental disorder and his gradual opening up to me as I attained adulthood,I would not have become interested in mental illness and the stigma that sur- rounds it.And if it weren’t for the support of my mother,no one in our family could have made it through. Both of them are the ultimate sources of this work. My wife,Kelly Campbell Hinshaw,has been a constant support,emotionally and intellectually.She is embarking on her own book project at present in or- der to give children everywhere the gifts of her artistic eye.My love and grati- tude are endless, Kel. My oldest son, Jeffrey Wyn Hinshaw, is embarking on adulthood,and my hopes are that he can blend science and compassion in his life work.It is for our youngest,Evan Robert Hinshaw,that I have my most fer- vent hopes—that he can grow up in a world that is far less prone to dehuman- izing and stigmatizing mental illness. Many authors say it, but it nonetheless true here: All of these people de- serve my deep accolades,but any errors or misstatements are fully my own. Although I have great hopes that this work will help to provide a surge of interest,enthusiasm,and rigor in an area that is continuing to rise in impor- tance,I will be pleased if these words help even one beginning research inves- tigator,one budding clinician,or one frustrated yet hopeful individual or fam- ily member who is dealing with mental disorder. I dedicate this book to all persons with mental illness,along with their caregivers and support systems. All we are asking for is a fighting chance. Contents Introduction ix 1 What Is Mental Disorder and What Is Stigma? 3 2 Perspectives From Social Psychology, Sociology, and Evolutionary Psychology 28 3 Historical Perspectives on Mental Illness and Stigma 53 4 Modern Conceptions ofMental Disorder 73 5 Evidence From Scientific Investigations 93 6 Indicators ofStigma From Everyday Life 115 7 Stigma ofMental Illness: An Integration 140 8 Research Directions and Priorities 157 9 Overcoming Stigma I: Legislation, Policy, and Community Efforts 176 10 Overcoming Stigma II: Media and Mental Health Professionals 202 11 Overcoming Stigma III: Families and Individuals 217 12 Concluding Issues 232 Notes 245 References 285 Index 317 This page intentionally left blank Introduction Mental illness has been part of the human condition for as long as our species has existed,affecting countless individuals,families,and communities.Major advances regarding mental disorders are now appearing with regularity,partic- ularly with respect to treatment options.Yet emotional reactions to mental dis- order are still dominated by fear,pity,and scorn; societal responses continue to be characterized by banishment,punishment,and neglect.Although the very nature of mental illness makes it understandable that empathy is difficult to sustain,the lack of respect and fairness signals deeper currents. At one level,things appear to be changing.People with mental disorders are “coming out of the closet”with increasing frequency.Celebrities and authors now openly disclose their stories of substance abuse,mood disorder and treat- ment with electroconvulsive therapy (Kitty Dukakis), postpartum depression (Brooke Shields), bipolar disorder (Jane Pauley), or suicidality (William Sty- ron); star athletes are coming forward with their experiences in therapy (for example,Alex Rodríguez, the New York Yankee and American League Most Valuable Player in 2005).1 Even those without celebrity status are more open and increasingly likely to admit that they see a therapist or take psychoactive medications such as Prozac or similar compounds.Have we in fact entered a new era of openness and tolerance? In 1999 President Bill Clinton and Tipper Gore sponsored the first-ever White House Conference on Mental Health.2This conference made public the importance of mental disorder and stated explicitly that people with mental disorders must be accorded the same respect as those with physical illnesses. During that same year the Surgeon General of the United States, Dr. David Satcher,released a report on mental disorder,the first such report ever to em- anate from that high office. Noteworthy in this landmark document was the ix