From Psychiatric Patient to Citizen: Overcoming Discrimination and Social Exclusion By Liz Sayce. Basingstoke: Macmillan. 2000. 280 pp. £13.99 (pb). ISBN 0 333 69890 8

Ten years ago, when I worked on a hospital psychiatric ward, I used to coordinate a weekly therapy group for the patients. As time continued, it became increasingly difficult to maintain any pretence of pure group therapy. The group members simply wanted to talk about the effects of their hospitalisation on family and friends, and wanted advice on everyday self-presentation and whether to conceal their hospital admission from potential employers. Eventually, our group became known on the ward as the “ stigma group”. Today, with the College's Changing Minds campaign, the issue is pertinent to all psychiatrists because we have accepted finally that popular knowledge about mental illness affects users of psychiatric services not only in their readiness to seek and accept treatment, and in their return to a full social role but, perhaps, in the actual clinical outcome (as, for example, in schizophrenia; WHO Determinants of Outcome Study).

Liz Sayce, a health professional who has previously worked for Mind, comes out in favour of ‘discrimination’ rather than ‘stigma’, in that the latter is too individualised: ‘discrimination’ better places responsibility on the wider society. Similarly, she favours ‘inclusion’ rather than ‘integration’. In this study of social attitudes and responses in the USA and Britain she often refers to the relative success of campaigns combating racism. Indeed, I noted last year a London campaign entitled Mad Pride, which sought to emulate the arguments of antiracist campaigns (although not to the extent of France, where I was given a campaign button reading, in French, “Schizo? So what? What's your problem?”).

One of the more sobering recollections here for our new-found enthusiasm for reducing the public stigma of mental illness is just how much psychiatry in the 20th century has been responsible for discriminating policies, from eugenics and sterilisation to immigration controls and segregation. In considering the success of various anti-discrimination campaigns, Sayce shows how slight differences of emphasis may often invalidate the next campaign: from ‘safe (but) with effective treatment’ to just plain ‘safe’. She reviews the generally useful results of the 1990 Americans with Disability Act (ADA), particularly for those with milder psychological problems who are professionally trained or otherwise socially advantaged (note the similarities to middle-class African Americans and antiracism legislation); and contrasts the ADA with the less powerful British Disability Discrimination Act of 1995. She considers the relative advantages of four possible antidiscrimination models: the ‘brain disease model’ — you are not responsible for your illness, it is a disease like any other; the ‘individual growth model’ — we are all struggling along the same continuum to health and autonomy; the ‘libertarian model’ — just say “Hands off!”; the ‘disability inclusion model’ — piecemeal and case focused. Her preference seems to be for the last, but she notes that in any campaign we must apparently proceed simultaneously on all fronts: economic, employment, ideological, public and private.

This is essentially a practical (and useful) guide to policy and campaigning, arguing what has worked and what has not. The wider issues of the origin of stigma, and how societies at different times privilege one or other type of exclusion, depending on their special interests, are not discussed.