The media perpetuate stigma, giving the public narrowly focused stories based around stereotypes. As with racial prejudice, stereotypes make people easier to dismiss, and in so doing, the stigmatiser maintains social distance. Stereotypes are about selective perceptions that place people in categories, exaggerating differences between groups (‘them and us’) in order to obscure differences within groups ( Reference TownsendTownsend, 1979). Stigma (like beauty) is in the eye of the beholder, and a body of evidence supports the concept of stereotypes of mental illness ( Reference TownsendTownsend, 1979 Reference PhiloPhilo, 1996 Reference ByrneByrne, 1997). Goffman (1963) commented that the difference between a normal and a stigmatised person was a question of perspective, not reality. By way of summary, Gullekson (in Fink & Tasman, 1992) writes about her brother's schizophrenia: A civilisation should be judged by how it treats its mentally ill: discrimination is also about the conditions in which our patients live, mental health budgets and the priority which we allow these services to achieve. Discrimination occurs across every aspect of social and economic existence ( Reference Fink and TasmanFink & Tasman, 1992 Reference Heller, Reynolds and GommHeller et al, 1996 Reference Read and ReynoldsRead & Reynolds, 1997 Reference ByrneByrne, 1997 Reference Thompson and ThompsonThompson & Thompson, 1997). Patients who pursue the secrecy strategy and withdraw have a more insular support network. The reality of discriminatory practices supplies a very real incentive to keep mental health problems a secret. Negative cultural sanction and myths combine to ensure scapegoating in the wider community (see Box 1). The question arises as to just what all this shame and secrecy is about. Poorer outcomes in chronic mental disorders are likely when patients' social networks are reduced ( Reference Brugha, Wing and BrewinBrugha et al, 1993).
So, unlike physical illness, when social resources are mobilised, people with mental disorders are removed from potential supports. Secrecy acts as an obstacle to the presentation and treatment of mental illness at all stages. Professionals are no different in this regard, and hide psychiatric illness in themselves or a family member. In one study of 156 parents and spouses of first-admission patients, half reported making efforts to conceal the illness from others ( Reference Phelan, Bromet and LinkPhelan et al, 1998). Family and friends may endure a stigma by association, the so-called “courtesy stigma” ( Reference GoffmanGoffman, 1963). Commenting on the barriers to the management of depression, Docherty (1997) cites both patients' shame in admitting to, and physicians' reluctance to enquire about, depressive symptoms. The adaptive response to private and public shame is secrecy.
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