The stigma of silence ===================== * Ronald Ruskin **Nothing to hide: mental illness in the family** Interviews by Jean J. Beard and Peggy Gillespie Photographs by Gigi Kaeser New York: The New Press; 2002 296 pp US$59.95 (paper) ISBN 1-56584-721-0 ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/168/10/1301/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/168/10/1301/F1) ![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/168/10/1301/F2.medium.gif) [Figure2](http://www.cmaj.ca/content/168/10/1301/F2) Photo by: Fred Sebastian Ignorance, silence, fear, disbelief, misunderstanding and blame are common reactions to people with mental illness. In the foreword to *Nothing to Hide,* Kay Jamison writes that stigma against mental illness is ancient, prevalent in all societies, and continues to adversely influence public and political responses. Jamison speaks with authority, not only as a professor of psychiatry at John's Hopkins School of Medicine, but also as someone with bipolar disorder who remained formidably ill and untreated for many years. As she confides, I first became ill with a severe form of manic-depressive illness when I was a senior in high school. Like many people who get psychiatric disorders, I had absolutely no idea what was happening to me. ... I finally received medical care — more than ten years after my first breakdown. One of the ironies of mental illness is that by ignoring painful symptoms patients may stigmatize themselves further. Family members also suffer as a result. In the introduction to *Nothing to Hide*, Kenneth Duckworth, also a psychiatrist, tells of a shattering experience in grade two when his father suffered a manic breakdown: I assumed that my situation was unique, that no one else was experiencing the anxiety and fear that accompany a big and poorly understood condition like bipolar illness. Had I been able to imagine that millions of American kids were dealing with a variation on this theme, I would have felt less alone. Duckworth's account, like Jamison's, underscores a tragically common circumstance: people with mental illness often have symptoms for many years before they seek help. Bewildered and unsettled, they struggle in a society that neither empathizes with nor understands their predicament. This book takes the reader on a journey to unstable regions of the psyche: anxiety, depression, panic, schizophrenia, eating disorders, mania, suicide, obsessive compulsion and substance abuse. In describing common psychiatric disorders and their treatment, Duckworth dispels some of the myths perpetuated in the media — for example, that psychiatric patients are violent. (Statistically, they are not.) Mental illness is, unfortunately, quite common. The US National Institute of Mental Health estimates that 22.1% of Americans aged 18 and older — about 1 in 5 adults — suffer from a diagnosable mental disorder. Using the 1998 US census, Duckworth translates this figure to 44.3 million Americans. Assuming a similar prevalence in this country, over 4 million Canadians have a mental illness. Who has not had to share the pain of a family member, classmate, colleague, friend or lover struggling with mental illness? As if coping with the symptoms of the illness were not bad enough, there is, as Beard and Gillespie argue, “an additional challenge: the pervasive and destructive burden of stigma. Stigma gives rise to myths, stereotypes, and misunderstandings.” Beard and Gillespie travelled across America to interview families affected by mental illness, later presented the results of their project as a touring exhibit, and have now published this book to reach a broader audience. This book includes interviews with 44 patients and their family members, accompanied by black-and-white photographs by Gigi Kaeser. What emerges is an album of mental illness from a first-person perspective. Although there have been excellent popular books in recent years on mental illness, such as Kay Jamison's *An Unquiet Mind*, Andrew Solomon's *Noonday Demon*, William Styron's *Darkness Visible* and Mark Vonnegut's *The Eden Express*, the narratives in *Nothing to Hide* illuminate a dark collective wisdom. Here is a sampling of voices. Trinidad Azusa tells us, I was working as a tax auditor when … symptoms of my illness suddenly appeared without warning … [P]eople were always watching me. I would walk by the TV set and think the voices of the actors were talking directly to me … [A]t work things got very difficult … [M]y dad and my older brother took me to the hospital ... I was initially diagnosed with schizophrenia … I was in denial at first … [E]ven though I knew something was seriously wrong with me, I didn't want to believe I was mentally ill. Jodi Campbell writes of her sister's schizophrenia: When my sister Jamie first became ill, I was in my last year of middle school. I was scared all the time … I never knew what was going on … . None of us in the family knew what was wrong. At first I tried to isolate myself from my sister … I struggled with every single emotion you can think of … [O]ne day I walked into the kitchen and found Jamie lying on the floor … . I'd get scared because I didn't think I could let her out of my sight. Paul Gottlieb, a successful publishing executive struggling with a mood disorder writes: Where I worked, if you had a heart problem or cancer, you'd never find a more sympathetic, supportive group of people … but for years I had to be secretive about my mental illness because I was in control of millions of dollars of the corporation's assets, and I couldn't run the risk of having my judgment mistrusted. Fred Frese says, I was diagnosed with paranoid schizophrenia when I was only twenty-five … [F]or the next ten years I was in and out of various mental hospitals ... . Today I am the Director of Psychology at Western Reserve Psychiatric Hospital … [T]he thing is, people do recover. Molly Cisco says, I can remember lying in a snowdrift … when I was six, looking up to the stars, and wishing that my life would stop, that everything would stop. The patients who tell their stories in this book are old, young, urban, rural, and from various cultures and socioeconomic strata. Many feel anger toward medical or legal systems for failing to understand and help; others feel rage and despair at the postmorbid changes in their sense of self. There are stories of hope, of the persistence of severe mental disorders, and of suicide. As a psychiatrist I was deeply moved and informed by the candour of these narratives. The direct power of each voice to convey the raw material of life, the truth of mental illness, is penetrating and profound. The reader follows each narrative, peers into the photos, and senses anguish. This text is essential reading for medical professionals and the public. **Ronald Ruskin** Department of Psychiatry University of Toronto Director, Day Hospital Mount Sinai Hospital Toronto, Ont.