My dad had a striking form of bipolar disorder. Beginning during his late teen years, his episodes would escalate fast into grandiose bouts of mania, followed by miraculous recoveries after months of incomprehensible behavior. Not everyone with bipolar illness shows such distinct manias and depressions, but until relatively late in his life, my dad showed this extreme, classic pattern.
Not surprisingly, when he took on a separate personality, so different from his usual self, my world turned upside down. When he vanished into horrendous mental hospitals after fast-rising bouts of madness, I was frozen in time, not even daring to wonder where he might be. Following his return after weeks or months of shutdown, he was rational, calm, and responsive, my go-to person when I felt confused or upset.
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As strong as my mom was—holding the family together through sheer force of will—she didn’t want to see me sad or angry. It might remind her of another man in the house whose emotions could threaten destruction, so I learned to keep things in.
When my sister and I were quite young, my dad asked his psychiatrist what he should say about his chilling absences. The reply came without hesitation: “Never discuss mental illness with your children: Any such knowledge will permanently destroy them.” Unconditionally and professionally ordered, the entire topic was off limits.
In other words, during the 1950s the psychiatric profession forbade family members from knowing about the very forms of illness under its care. Would an oncologist direct a patient never to divulge his or her cancer to family members—or a cardiologist, heart disease? It’s unthinkable. But mental illness was so shameful that banning all discussion was believed to be therapeutic.
For the past couple of decades, I’ve been engaged with the concept of stigma. This term is defined as the shame and degradation meted out to members of social groups believed to be unworthy, dirty, or untouchable.
From its Greek origins, stigma signified a literal mark or brand. Coming to the agora, the public marketplace, a citizen in ancient Athens might have wondered who had fought for Sparta or who was a former slave. A burned mark into the skin publicly announced such status—a physical stigma, an observable mark of disgrace to define true outcasts.
In modern times, such actual marking still sometimes occurs. Concentration camp inmates in Nazi Germany were branded with numbers. During the early days of the epidemic, individuals with HIV in certain countries were also physically marked. Yet the vast majority of stigma today is psychological, referring to the subtler but still devastating mark of simply being part of an unfit group. Stigma pollutes any interactions between such individuals and members of mainstream society, containing the clear message that the outsiders are unworthy and despicable.
Throughout history and across cultures, many characteristics have been stigmatized, including physical deformity or disability, diseases like leprosy (now known as Hansen’s disease), minority status with respect to race or religion, any sexual orientation other than heterosexual, being adopted, or having a mental illness. Some of these are overt and visible, such as race, physical disability, and many chronic diseases. “Lepers,” as they were called—noxiously equating the person with the disease—could be distinguished by their scaly, dark-toned, disfiguring skin lesions. Yet other stigmatized traits, like sexual orientation, being adopted, or having a history of mental disorder, are potentially concealable. These kinds of hidden stigmas are especially troublesome, because the individuals in question may constantly wonder whether their characteristics are “leaking,” adding tension and uncertainty to every social encounter.
Think of the choices people like my father had to make—and, far too often, still do: Can anyone tell? If my secret of being insane, a madman, comes out, I’ll be shunned. Covering up completely is the only course. Stigma breeds shame; stigma breeds silence.
As cultures evolve, a number of formerly stigmatized traits or attributes can become far more acceptable. Left-handedness was formerly disgraceful but hardly seems an issue today. Strikingly, rapid shifts in societal attitudes toward gay marriage have emerged over the past two decades, fueled largely by young people. Such positive trends give real hope for tolerance and acceptance. Yet mental illness has received extremely harsh stigma throughout history and across nearly all cultures.
Three attributes, in fact, rank at the bottom of social acceptance in current attitude surveys: Homelessness, drug abuse, and mental illness. The general public does not wish for close contact with such individuals, instead desiring social distance. Even more, on the typical scales and questionnaires used in such research, respondents are likely to underplay their negative attitudes to avoid being perceived as bigots. Privately held attitudes may actually be far worse.
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During the silent 1950s, when I was young, mental illness was stigmatized to the extreme, linked in the public’s mind with utter incompetence as well as major potential for violence. Over half a million Americans were placed involuntarily in crowded, inhumane public mental hospitals, many of which resembled snake pits. The very term “mental illness” made one a complete outcast. Our family was caught in the crossfire.
In fact, because of the doctor’s orders, no could one let on that anything had changed. We were all engaged in serious play-acting, the costumes stiff and the scenes perplexing, without rehearsal. Over time, we ended up pretending that we weren’t pretending, enacting the ultimate in fantasy role-play. Each performance was live, and we performed our roles as though our lives depended on their success.
Why were the most important things in our family’s existence such an ongoing mystery? Whatever lay behind the silence must have been so devastating that it would have destroyed us if brought into the open.
Stigma is another kind of madness, the worst kind of all, beyond mental illness itself. Enforced silence—motivated by shame and advocated until recently by the mental health profession—produces disastrous consequences for all involved. Of course, disclosure is always a matter of timing, judgment, and prudence, but the fight must take place against the default assumption that opening up is harmful and must never occur.
As a boy I knew nothing of the term stigma, but what I did know was that something unimaginable lay just beneath the calm exterior of our family—and whatever it was could never be mentioned. What I did feel, in the rare times I allowed myself emotions, was that I might plunge so far down a steep chasm that I’d never claw my way up to the surface. To invoke an overused phrase, the shame, stigma, and silence were deafening. There were no awards handed out to our family for our acting ability but we deserved, at the very least, nominations in all the major categories.
Stephen P. Hinshaw is a professor of psychology at the University of California, Berkeley. This essay is partly adapted from his new book, Another Kind of Madness: A Journey Through the Stigma and Hope of Mental Illness, out now.
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