Photographs in this book show an African boy chained to a bench, and ‘cage beds’ used in central European asylums. Such violations of dignity and freedom must be stopped. But if we are serious about preventing stigma, we also have to support the entitlements associated with ‘second-generation’ reforms in more enlightened countries. And that is where it gets tricky.

This book delivered a clear, important and depressing message: that much of what we thought we knew about stigma prevention turned out to be wrong. Campaigning optimists (like me) might once have thought that ‘stigma reduction requires well-developed plans’, that ‘science is the best guide for programmes’ and that ‘improved knowledge about mental illness will eradicate stigma’. Sadly, such optimism wilted in the light of experience and the research evidence that is succinctly summarised in this book.

The first section challenges these faulty anti-stigma ‘paradigms’ (they are clearly not ‘paradigms’, but we will return to that in a moment), and the second part offers practical guidance on establishing anti-stigma programmes. The guidance is straightforward and sensible (e.g. select ‘target groups’, ‘use media wisely’ and ‘identify lessons learned’). It is the paradigms we need to think carefully about. The punning ambiguity of the title suggests Thomas Kuhn's scientific ‘paradigms’, whose conventions are periodically overturned by scientific revolution; and Milton's epic poem about the Fall of Adam and Eve, and their struggle for redemption. Anti-stigma work requires a vision and a call to arms, but campaigns may be prone to a Milton-style ‘splitting’ between the forces of good and of evil. This book teeters in places on the brink of an ‘us and them’ stance. When psychiatric nurses describe patients with borderline personality disorder as ‘difficult, annoying, manipulative and attention-seeking’, are those stigmatising descriptions or accurate reflections of the interaction with staff? Is it stigmatising to acknowledge that mentally ill people sometimes – rarely – carry out acts of violence? Is it accurate to say that ‘the placement of patients into communities has… exacerbated negative attitudes and contributed to higher morbidity and mortality’?

According to Kuhn, a paradigm does not describe just current theory and practice, but the entire world view that supports it. We should avoid a zero-sum situation whereby the destigmatisation of one group is only achieved by the demonisation of another. This is especially important since, as the authors note, research suggests that ‘prejudice was only rarely a valid predictor for discrimination’.

Unhelpful or inconsiderate behaviour may sometimes be based on wilful intolerance, emboldened by power. We could accurately label that ‘stigma’ and condemn it. But this leaves a wider puzzle unsolved: if less egregious forms of discrimination are not caused by bad people, nor motivated only by prejudice, what is going on?

We are all opposed to the stigma of mental illness, but that is not enough. We needed this book to remind us of what we previously misunderstood, and to reinforce what we now know. As Kuhn said, ‘looking at a contour map, the student sees lines on paper, the cartographer a picture of a terrain’. We may be redrawing our old map, but we have not – as yet – found a new one.