Mentalism (discrimination)

Mentalism (also known as sanism) is a form of discrimination and oppression against people based on presumed mental type (e.g. ADHD, bipolar or schizophrenia), mental action (e.g. stuttering or Tourette syndrome), supposed intelligence, or neurology (e.g. neurotypical or autism spectrum disorder), especially against those diagnosed with a mental disorder or a mental illness.

Like other "isms" such as sexism and racism, it is characterized by complex social inequalities in power. It can result in blatant mistreatment or multiple, small insults and indignities. The negative attitudes and terms may be internalized. Terms with a similar meaning in some usage are "sanism" (from sane) and "psychophobia" (which may also refer to a general fear of the depths or potentials of the mind).

Origin of terms
The term 'mentalism' emerged in the 1970s out of the psychiatric survivors movement, mentioned specifically by Judi Chamberlin in a well-known book of the period "On Our Own", published in the United States in 1978. People began to recognize a pattern in how they were treated, a set of assumptions which most people seemed to hold about mental (ex)patients regardless of whether they applied to any particular individual at any particular time - that they were incompetent, unable to do things for themselves, constantly in need of supervision and assistance, unpredictable, likely to be violent or irrational etc. It was realized that not only did the general public express mentalist ideas, so did ex-patients, a form of internalized oppression.

As of 1998 the term had been adopted by some consumers/survivors in the UK and the USA, but had not gained general currency. This left a conceptual gap filled in part by the concept of "stigma", which allegedly does not focus so much on institutionalized discrimination with multiple causes, but on whether people perceive mental health issues as shameful or as worse than they are. Nevertheless, a body of literature demonstrated widespread discrimination across many spheres of life, including employment, parental rights, housing, immigration, insurance, health care and access to justice.

The term 'sanism' has been attributed to US lawyer Michael Perlin. However, Perlin stated in a conference paper in 2009 that to the best of his knowledge the word was coined by Dr Morton Birnbaum, as sourced to a book and and legal case from the 1970s. Birnbaum was a physician, lawyer and mental health advocate who helped establish rights to treatment and safeguards against involuntary confinement; he died in 2005. Perlin says he has been relying on the term 'sanism' for the past 20 years, including in published papers since the early 1990s.

Social divisions
Mentalism, at an extreme, may lead to an overly categorical dividing of people into an empowered group assumed to be normal, healthy, reliable, and capable, and a powerless group assumed to be sick, disabled, crazy, unpredictable, and violent. This divide can justify inconsiderate treatment of the latter group and expectations of poorer standards of living for them, for which they may be expected to express gratitude. Further discrimination may involve labeling some as "high functioning" and some as "low-functioning". While this may relate to some real issues and may enable the targetting of support resources, in either case human behaviors are recast in pathological terms.

The discrimination can be so fundamental and unquestioned that it can stop people truly empathizing (although they may think they are) or genuinely seeing the other point of view with respect. Mentalism may lead a person to erroneously believe they understand the other's situation and needs better than they do themselves.

Sadly, even among those who experience disability discrimination, it has been reported that internationally "there is a lot of ‘sanism’ in the disability movement" and "Disability organisations don’t always 'get' mental health and don’t want to be seen as mentally defective."

Clinical terminology
Mentalism may be enshrined in clinical terminology in subtle ways, including in the basic diagnostic categories used by psychiatry (as in the DSM or ICD). There is some ongoing debate as to which terms and criteria may stigmatize or communicate contempt or inferiority, rather than faciliate understanding of people's real issues. Some oppose the entire process as 'labelling', and some have responded to justifications for it - such that it is necessary for clinical or administrative purposes - to the way a person may justify the use of ethnic slurs because they intend no harm. Others argue that most aspects could easily be expressed in a more accurate and less offensive manner.

Some clinical terms may be used far beyond their usual meanings, in a way that may obscure the regular human and social context of people's experiences - for example, having a bad time may be assumed to be decompensation; incarceration or solitary confinement may be described as "treatment" regardless of benefit to the person; regular activities like listening to music, engaging in exercise or sporting activities, or just being in a particular physical or social environment (milieu), may be referred to as "therapies"; all sorts of responses and behaviors may be assumed to be "symptoms"; core adverse effects of drugs may be termed "side" effects.

Blame
Interpretations of behaviors, and applications of treatments, may be done in an arrogant unjustified way because of an underlying mentalism, according to critics. If a recipient disagrees or does not change, they may be labeled as "non-compliant", "uncooperative" or "treatment-resistant". This is despite the fact that it may be due to inadequate understanding of the person or his/her problems, medication effects, a poor match between the treatment and the person's lifestyle, stigma associated with the treatment, difficulty with access, cultural unacceptability, or many other issues.

Mentalism may lead people to assume that someone is not aware of what they are doing and that there is no point trying to communicate with them, despite the fact that they may well have a level of awareness and desire to connect even if they are acting in a seemingly irrational or self-harming way. In addition, it is argued that mental health clinicians tend to equate subduing a person with treatment; a quiet client who causes no community disturbance is deemed "improved" no matter how miserable or incapacitated that person may feel as a result.

Clinicians may blame clients for not being sufficiently motivated to work on treatment goals, and as "acting out" when goals are not agreed with or are found upsetting. Critics say that in the majority of cases this is actually due to the client having been treated in a disrespectful, judgmental, or dismissive manner. Such behavior may nevertheless be justified by blaming the client as having been demanding, angry or "needing limits". However, it is argued that power-sharing should be cultivated and that when respectful communication breaks down, the first thing that needs to be asked is whether mentalist prejudices have been expressed.

Neglect
Mentalism has been linked to negligence in monitoring for adverse effects of medications or other interventions, or to viewing such effects as more acceptable than they would be for others. This has been compared to instances of maltreatment based on racism. Mentalism has also been linked to neglect in failing to check for or respect people's past experiences of abuse or other trauma. Treatments that do not support choice and self-determination may cause people to re-experience the helplessness, pain, despair, and rage that accompanied the trauma, and yet attempts to cope with this may be labeled as "acting out", "manipulating" or "attention-seeking".

Mentalism can lead to "poor" or "guarded" predictions of the future for a person; a pessimistic view skewed by a narrow clinical experience, that can be impervious to contrary evidence because those who succeed can be discounted as having been misdiagnosed or as not having the "real" form of a disorder. While some mental health problems can involve very substantial disability and can be very difficult to overcome in society, predictions based on prejudice and stereotypes can be self-fulfilling because individuals pick up on a message that they have no real hope, and realistic hope is said to be a key foundation of recovery.

Institutional discrimination
Offensive and injurious practices may be integrated into clinical procedures, to the point where professionals no longer recognize them as discrimination, which has been described as a form of institutional mentalism. This may be apparent in physical separation, including separate use of facilities or accommodation, or in lower standards. Mental health professionals may find themselves drawn into systems based on bureaucratic and financial imperatives and social control, resulting in alienation from their original values and disappointment in "the system", and adoption of the cynical, mentalist beliefs that pervade such organizations. However, just as employees can be dismissed for disparaging sexual or ethnic remarks, it is argued that staff who are entrenched in negative stereotypes, attitudes, and beliefs about those labeled with mental disorders need to be removed from service organizations. A related theoretical approach, termed expressed emotion, has tended to focus on negative attitudes from care givers including within families.

At a society-wide level, mentalism has been linked to people being kept in poverty as second class citizens; to employment discrimination keeping people living on handouts; to interpersonal discrimination hindering relationships, to stereotypes promoted through the media spreading fears of unpredictability and dangerousness, and to people fearing to disclose or talk about their experiences.

In the consumer/survivor/ex-patient movement in Britain, Pete Shaughnessy, a founder of mad pride, concluded that the National Health Service in England is "institutionally mentalist and has a lot of soul searching to do in the new Millenium", including addressing the prejudice of its office staff. He suggested that when prejudice is applied by the very professionals who aspire to eradicate it, it raises the question of whether it will ever be eradicated. Shaughnessey committed suicide in 2002.

The Psychiatric Survivors Movement is said to be a feminist issue: "Our issues are important for all women because mentalism acts as a threat to all women. Survivors issues are likewise important to all women because mentalism threatens women's families and children."

A psychiatric survivor and professional has said that "Mentalism parallels sexism and racism in creating an oppressed underclass, in this case of people who have received psychiatric diagnosis and treatment". She reported that the most frequent complaint of psychiatric patients is that nobody listens, or only selectively in the course of trying to make a diagnosis.

The Law
Legal frameworks are traditionally based on definitons of sanity and insanity rather than the terminology of mental health and illness (or mental disorder) used in clinical frameworks, and the term 'sanism' may be used in response rather than 'mentalism'.

Michael Perlin, Professor of Law at New York Law School, has defined sanism as "an irrational prejudice of the same quality and character as other irrational prejudices that cause and are reflected in prevailing social attitudes of racism, sexism, homophobia, and ethnic bigotry that permeates all aspects of mental disability law and affects all participants in the mental disability law system: litigants, fact finders, counsel, and expert and lay witnesses."

Perlin notes that sanism "infects jurisprudence and lawyering practices in a largely invisible and largely socially acceptable way", based mainly on "stereotype, myth, superstition, and deindividualization." Its "corrosive effects have warped involuntary civil commitment law, institutional law, tort law, and all aspects of the criminal process (pretrial, trial and sentencing)." According to Perlin, judges are not immune from this, tending to reflect sanist thinking that has deep roots within our culture, resulting in judicial decisions based on stereotypes in all areas of civil and criminal law, expressed in biased language and showing contempt for mental health professionals. Courts are often impatient and attribute mental problems to "weak character or poor resolve".

Sanist attitudes are prevalent in the teaching of law students, both overtly and covertly, according to Perlin. He notes that this impacts on the skills at the heart of lawyering such as "interviewing, investigating, counseling and negotiating", and on every critical moment of clinical experience in terms of "the initial interview, case preparation, case conferences, planning litigation (or negotiation) strategy, trial preparation, trial and appeal."

There is also widespread discrimination by jurors, who Perlin characterizes as demonstrating "irrational brutality, prejudice, hostility, and hatred" towards defendents when there is an insanity defence. Specific sanist myths include relying on popular images of craziness; an 'obsession' with claims that mental problems can be easily faked and experts duped; assuming an absolute link between mental illness and dangerousness; an 'incessant' confusion and mixing up of different tests of mental status; and assuming that defendants acquitted on insanity defenses are likely to be released quickly. Although neuroimaging evidence has some potential to help in this area, Perlin concludes that it is very difficult to weigh the truth or relevance of it due to its many uncertainties and limitations, and because it may be either disregarded or over-hyped by scientists, lawyers or in the popular imagination. He believes that "the key to an answer here is a consideration of sanism", because to a great extent it can "overwhelm all other evidence and all other issues in this conversation". He suggests that only therapeutic jurisprudence "has the potential power to “strip the sanist facade” from this subject matter."

Perlin has suggested that the international Convention on the Rights of Persons with Disabilities may be the best tool to challenge sanist discrimination in forensic facilities.

Sanism in the legal profession can affect many people who at some point in their life may struggle with some degree of mental health problems, according to Perlin. This may unjustly limit their ability to legally resolve issues in their communities such as "contract problems, property problems, domestic relations problems, and trusts and estates problems."

Susan Fraser, a lawyer in Canada who specializes in advocating for vulnerable people, argues that sanism is based on fear of the unknown, reinforced by stereotypes that dehumanize individuals. She argues that this causes the legal system to fail to properly defend patients' rights to refuse potentially harmful medications; to investigate deaths in psychiatric hospitals and other institutions in an equal way to others; and to fail to properly listen to and respect the voices of mental health consumers and survivors.

Multiple discriminations
A spiral of oppression experienced by oppressed groups in society has been identified. Firstly, oppressions in society on the grounds of difference (for which terms may exist, such as racism, sexism, classism, ageism, homophobia etc.) can have a negative physical, social, economic and psychological effects on individuals, which may cause emotional distress and sometimes "mental health" problems. Society's response to such distress is to treat it within a system of medical and social care rather than understanding and challenging the oppressions that gave rise to it, thus reinforcing them with further oppressive attitudes and practices, which can lead to more distress, and so on in a vicious cycle. In addition, due to coming into contact with mental health services, people become subject to the oppression of mentalism, since society (and mental health services themselves) have such negative attitudes towards people with a psychiatric diagnosis, thus further perpetuating oppression and discrimination.