Psychiatrists are no strangers to the concept of stigma. It is a popular topic, from our professional societies to our research objectives. It is a subject that has gained prominence in broader media and public discourse and has inspired awareness months, campaigns, and human-interest stories. But in his book, Nobody’s Normal, Roy Richard Grinker strays from the typical narrative of stigma, which generally invites a discussion on educating the public and relying on high profile individuals to discuss their struggles. Instead, the author explores how culture creates and reinforces stigmatizing attitudes and beliefs. Importantly for mental health clinicians, his discussion encourages readers to consider whether our own goals and understanding of mental illness are driving the stigma that we lament.
Dr. Grinker is a Professor of Anthropology at George Washington University. He received his PhD in Social Anthropology at Harvard University and is the Editor-In-Chief of Anthropological Quarterly. His previous authorships reflect a special topical interest in Korea (Korea and Its Futures: Unification and the Unfinished War), sub-Saharan Africa (Perspectives on Africa; Companion to the Anthropology of Africa), and autism (Unstrange Minds), interests that are infused throughout the book. To understand the author’s relationship to the science of the mind and stigma, and thus the unique perspective he brings to the subject, it is helpful to understand his family background. His great-grandfather Julius Grinker, a respected neurologist, espoused stigmatizing views of people with mental illness and of psychiatry. His grandfather Roy Grinker, Sr., challenged these views when he chose to practice neuropsychiatry; he later went on to found the Institute of Psychosomatic and Psychiatric Research in Chicago and had a long career in psychiatric education. The author’s father and wife Joyce are also psychiatrists. His daughter has autism spectrum disorder, which fueled his interest in the subject. His family history is highlighted in the introduction of the book but continues as a thread throughout.
The book is divided into three parts. Each part represents another cultural pattern the author asserts contributed to the rise of stigma about mental illness. The first of these is entitled Capitalism, and discusses the value Western societies place on individualism and productivity. The second is War, with its pattern of learning and forgetting lessons on human vulnerability, treatment advances, and perceptions of mental illness. The third explores the dichotomy of Body and Mind; this part focuses on the medicalization of mental illness and our hunt for its genetic and neurological underpinnings. The author concludes by encouraging readers to think of illness as existing on a spectrum with which all people may have some experience over the course of their lives.
The book uses engaging and light prose that is inviting for audiences of all backgrounds. The author seamlessly knits case examples and stories from other countries to contrast how different cultures affect the understanding and treatment of people who are mentally ill or neurodiverse. Within Grinker’s narrative is the history of psychiatry and mental health care, from the days of the early custodial asylums complete with their torturous methods, through the creation of our diagnostic manuals, and our current attempts to elucidate the underlying genes and brain structures that contribute to mental illness. This history is told in a loose chronological order. Though the book is structured in three parts, each cultural pattern appears in its neighboring part such that they read not as individual cultural patterns but as patterns working in concert with each other. The reader is left with a deeper and richer appreciation of the roots of stigma, culturally and historically. And while a book that calls into question the motives and approaches of the mental health field may be off-putting for some, the author incorporates the narrative of his own family history throughout the book, which itself is a history of psychiatrists, their work, and their growth. This personal touch softens the parts of the book that may be perceived as critical, which may make it less alienating to a mental health audience.
While Grinker’s questioning of the medicalization of mental illness and our attempt to understand diagnoses raises interesting questions, it is not clear how his ideas would play out in the legal system. A forensic audience may be left wondering where the concept of criminal responsibility falls if all people are on a spectrum. Further, in one chapter, the author rightly lauds employers who have created work environments that are supportive of those who are neurodiverse or mentally ill, providing them with resources and accommodations. He encourages support and understanding throughout our social world, including praising differences rather than demanding conformity to societal expectations. But forensic evaluators may be left wondering how much support and understanding encourages autonomy of a defendant in competency assessments and restoration, and how much disrupts the dignity of legal proceedings leading to unfair trials and outcomes.
Grinker’s discussion of the lack of clarity of diagnoses and their cultural underpinnings is interesting and important. But for forensic psychiatrists who work in a setting where a degree of certainty is demanded and the psychiatric field is often called into question, portraying the illnesses we defend on the stand as predominantly culturally or socially derived may seem dismissive and trivializing. If culture and society have established the notion of illness (and its accompanying degree of understanding when those who are ill lack control over their actions), then culture and society may also withdraw such understandings. Forensic psychiatrists are often the mediators of the stigmatizing views of those caught in the legal system and those in the mental health system. The book reminds us that we stand on unsteady ground.
When considering the roots of stigma, I was struck by the author’s lack of incorporation of evolutionary theory. Evolution itself can shape culture. For instance, the culture of capitalism with its distaste for those who do not “do their part” has roots in our drive toward fairness and rooting out free riders.1,2 The warmth and understanding we feel toward soldiers during war that is soon forgotten after its conclusion has roots in group dynamics that promote empathy and care toward ingroup members, particularly during conflict.3 It is difficult to see how we can eliminate stigma if the culture that we are trying to change has primal and ancestral underpinnings. At the very least, if we do not appreciate these underpinnings and do not try to address them, then our efforts to change culture are cosmetic at best.
Overall, this book is an important and interesting read. It inspires discussion and reflection, whether one agrees with its basic tenets or not. It reminds us that we are at a single point in an ever-changing culture and history, which is a profound and humbling thought indeed.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2022 American Academy of Psychiatry and the Law
