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The Image of Madness: The Public Facing Mental Illness and Psychiatric Treatment

University of London, Department of General Psychiatry, St George's Hospital Medical School, London SW17 ORE

EDITED BY SIDNEY CROWN and ALAN LEE

Edited by J. Guimón, W. Fischer & N. Sartorius. Basel: Karger. 1999. US$128.75 (hb). ISBN 3 8055 4546 0

The theme of this book is the public's perception, often stigmatising, of mental illnesses and the impact this can have on compliance with pharmacological methods of treatment. This is considered in relation to strategies for tackling stigmatisation and related discrimination against medical interventions in particular. The hand of the pharmaceutical industry is obvious but, although this has influenced the book's orientation, there is also much of a general nature to appreciate. The book has a strong Swiss base, in the form of authorship of 10 of the 22 chapters.

Several substantial studies of the social representations of mental illnesses in the public mind and also among health care professionals are reported. For psychiatrists, often accused of detrimentally labelling those with mental distress, it is interesting to be reminded that pigeon-holing and labelling deviant groups is a universal proclivity. The public's crude categorisation is into the ‘seriously mad’ and the ‘less seriously distressed’. Criteria are behavioural, with emphasis on violence. Only under such circumstances is the intervention of psychiatrists welcomed. The public's perception of schizophrenia, predictably, is found yet again to be akin to the psychiatric concept of multiple personality disorder. The blame for this should be laid squarely on Bleuler and his redefinition of the core features and mechanisms within the syndrome, thereafter misconstrued and avidly taken up by society at large. Overall, the text makes little attempt to challenge the public's crude categorisation of those with mental illness, focusing as it does almost exclusively on schizophrenia. Authors have little doubt that it is the most stigmatised of the mental illnesses, whereas the Royal College of Psychiatrists' own survey of public opinions of the wide range of mental illnesses shows that people with drug or alcohol addiction are most negatively perceived. The doubtless even more seriously stigmatised group of people with antisocial personality disorder is also not considered here.

There are early interesting chapters on the metaphorical status of schizophrenia in particular and the methodological problems and profound weaknesses of much ‘attitude research’. The reader is reminded that responses to survey-type questions concerning alleged attitudes but exclusively within the cognitive domain can be far removed from affective reactions and related behaviours. Correspondingly, exclusively educational efforts to change attitudes are revealed as sterile, at least in the short term. Contact with and supervised personal experience of people with mental illnesses is slightly more effective, especially — but still only moderately so — among health care workers such as medical and nursing students in systematic clinical programmes. There is a good medico-political statement by Sartorius in this section of the book, with reference to the World Psychiatric Association's global campaign to combat stigmatisation of people with schizophrenia and the strategies and instruments being developed for that purpose.

Two-fifths of the book is given over to studies concerning non-compliance, largely in relation to neuroleptic medication. Chronicity, lack of insight, search for autonomy, fear of addiction, fear by both the patient and the family of labelling and ever greater discrimination are among the relevant factors. The book ends with two good chapters from North America by DiMatteo and Thorne, respectively. Both embed the subject of non-compliance within the larger contexts of medical treatment of chronic disease in general and of the doctor—patient interaction. They point the way to more fulfilling doctor—patient relationships and greater acceptance by patients of credible offers of treatments.

The book is a useful addition to the still sparse literature addressing the stigmatisation of people with schizophrenia.

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