By Coni Kalinowski, M.D. and Pat Risser

This essay is being reproduced here, in full, by permission of co–author Pat Risser. Please go to his own Site for more on this topic.

I will reproduce this here, word for word, divided into three page segments.

Segment 1:

Mentalism is a term coined by author and activist Judi Chamberlain to describe discrimination against people who have received psychiatric treatment (1). Like other "isms," such as racism and sexism, mentalism is characterized by complex social inequities of power that result in the pervasive mistreatment of people who have been labeled "mentally ill." Some of this mistreatment is blatant, such as being stripped and locked in a cold room or being beaten during physical restraint. However, like all discrimination, mentalism is even more commonly expressed in the multiple, small insults and indignities that the labeled person suffers every day. Dr. Chester Pierce, an African-American psychiatrist and author writing about racism, termed these small attacks "micro-aggressions" (2).

Individual micro-aggressions tend not to be powerful in themselves. To understand their impact upon people, one must consider that the person is subjected to hundreds or even thousands of these denigrating, disrespectful communications each day over years. These micro-aggressions have a cumulative effect. In the US, we are constantly surrounded by derogatory language regarding psychiatric problems ("He's a basket case." "You're nuts." "What a loony tune."), negative stereotypes about anyone who seeks mental health services, hostility ("They need to be locked up."), and sensationalistic media stories depicting people as crazed killers and "dangerous mental patients".

Over time most people cannot help but be affected by this barrage of abuse. Many people who have experienced psychiatric treatment internalize these negative attitudes and begin to feel badly about themselves (3,4,5). People may feel ashamed or blame themselves for their difficulties, feel worthless and hopeless about their futures, or lose confidence in their abilities. Often, people find that they must hide their histories, and live in fear of losing their job, their friends, or their credibility. These reactions to discrimination can become devastating to people as they begin to direct more and more of their anger and helplessness back at themselves.

Unfortunately, in the field of mental health, we rarely recognize or acknowledge the power of mentalism. Instead, the person who is demoralized by his or her treatment as a "mental patient" is more likely to be rediagnosed, labeled "treatment resistant," or offered more medication. A mental health professional will rarely address the issue of discrimination as a focus of services, and often, we are more likely to contribute to the problem than to help.

Those of us who provide mental health services are certainly not free from the influence of mentalism. Offensive and injurious practices are integrated into everyday clinical procedures to the point where we no longer recognize them as discrimination and find it strange that anyone should question our approach. Yet these unintentional micro- and macro-aggressions are no less damaging to the people we serve. We are also subject to the influences of mentalism in the sense that if we try to change our mentalist attitudes or those of our fellow practitioners we may find that we are questioned, challenged, spurned and even disdained.

It is always unpleasant to discover that we have been acting to oppress others. It is equally uncomfortable to consider relinquishing power to others. However, if we truly want to help people to recover and heal, we must address the impact of mentalism upon their health and well-being. We need to do everything possible to eliminate mentalist practices from our services. To truly combat mentalism we must move beyond superfluous changes that make us sound politically correct. We need to earnestly challenge our own assumptions and attitudes in order to personally recover from the prejudices we have learned.

Us vs. Them

Mentalism, like all the "isms," separates people into a power-up group and a power-down group. In the case of mentalism, the power-up group is assumed to be "normal," healthy, reliable, and capable. The power-down group, composed of people who have received psychiatric treatment, is assumed to be sick, disabled, crazy, unpredictable, and violent. This black-and-white style of thinking is referred to in psychodynamic literature as "splitting."

Splitting paves the way to establish a lower standard of service to the power-down group. An apartment that is too run down for "us" is good enough for "them." Side effects that "we" would never tolerate should not interfere with "their" compliance. Medication risks that "we" find unacceptable are reasonable for "them." "We" need credit cards to extend our salaries, but "they" need to budget their social security income to the penny. The assumptions of mentalism are further recruited to justify these inequities, as for example, "forcing 'them' to take medications that cause tardive dyskinesia is necessary because 'they' are sick and 'we' are not." Mentalism, like racism, is also used to justify violence. If "we" were jumped upon by a group of people, taken down and forcibly injected with powerful medications, then locked up and tied down in isolation, it would be considered assault and battery, kidnapping, or torture. If we do this to "them" in a hospital, it is "treatment" for their own good.

Mentalist splitting also allows the power-up group to judge and reframe human behaviors in accord with the power dynamic. The behaviors of the power-down group are framed in pathological terms while the same behaviors are excused or even valued in members of the power-up group. For example, a psychiatrist colleague who threw abusive tantrums at nursing staff was seen as "authoritarian" and "running a tight ship" while people receiving care on the same unit were forcibly medicated and secluded for the same "inappropriate" behavior.

Of course, we all know from personal experience that most people don't fit into either of the artificial extremes created by splitting. Most of us have good and bad periods in our lives, times of good and bad judgment, strengths and weaknesses, and periods of distress and of health. Rather than acknowledging that splitting is a distortion of reality, mentalist thinking has led people to establish a category that we would call "almost us": "high-functioning."

The "high-functioning patient" is generally a person who is just like "us" in every way except one - his or her psychiatric label. The power-up group can feel gratified that they have recognized the person's contributions by acknowledging that the person isn't "just one of them," yet the person retains his/her cautionary label and all the negative stereotypes that go with it. Other individuals are given the designation "low-functioning" which clearly conveys the perception that the person does not make valuable contributions and is considered to be of lower worth to the community (6). At times the "low functioning" label can be used punitively to describe a consumer who challenges the power of the staff.

"About twenty years ago, I'd been hospitalized several times for suicide attempts. My initial diagnosis was schizophrenia but, that changed each time I saw a different doc or therapist. The diagnosis also changed depending upon what the insurance companies were likely to pay for at any given time. I'd taken and tried most of the psychiatric drugs available at the time. I'd been in and out of day treatment several times.

The day treatment I was in at the time was changing. They were going to create two new levels. One level would be for the "high functioning" and the other would be a longer term, more elementary program for the more hopeless cases who were designated "low functioning." I fell into the latter group because I had the audacity to challenge one of the therapists.

Of course, in every hospital and in every treatment program in which I'd participated, there was the same old worn out standard fare. They would have groups which included stress management, assertiveness, recreational therapy (RT) also known as play time and of course, occupational therapy (OT) which is another name for ceramics and other useless arts and crafts sorts of activities.

One day, I'd grown bored with hearing the same thing repeated in eight week cycles and so, as assertiveness group was beginning, I challenged the therapist. I claimed that I could run the group as well or better than they could. Naturally, this upset the poor fellow and in his flabbergasted state, he accepted my challenge. He haughtily assumed that I'd fail miserably and thereby be set in my proper place.

I approached the front of the room with confidence and calmly proceeded to articulate a method of understand assertiveness which was far in advance of that which he was going to teach. Flustered, he got up in a huff and left the room to the cheers of the dozen or so of my fellow compatriots who were present.

From that day forth, I was known as "treatment resistant" and "low functioning" among the treatment staff but, I was elevated to a sort of informal "senior client" status amongst my friends." -P.R.

Labeling someone as either high-functioning or low-functioning has no healing impact upon the person in distress and in fact, can have quite the opposite effect. It can cause them to feel more hopeless and helpless and thus iatrogenically more distressed than before being labeled in this pejorative way. The cumulative effects of this sort of micro-aggression can even cost lives.