Sanism and the language of mental illness

As I was reading about the stigma of mental illness, I was struck by the lack of a mainstream term to describe the discrimination that arises from that stigma. This void in our everyday terminology is telling: it implies that the oppression people with mental illness face is so commonplace and routine that it doesn’t merit its own label. I submit that until we name it, we can’t effectively discuss it, and the absence of this name makes it easy for many of us to ignore it or deny its existence.

Advocacy and research organizations such as the Mental Health Commission of Canada tend to use the term “mental health stigma,” but I’d argue that finding a single word to describe discrimination against people with mental illness helps put it on par with similar forms of bigotry, including racism and sexism.

Sanism versus mentalism

Two terms that have been proposed to label the discrimination against people with mental illness are sanism and mentalism, which have appeared in legal and social science research circles but haven’t caught on with the public or with mass media. Sanism was coined by attorney Morton Birnbaum in the 1960s, when he was representing Edward Stephens, a patient with mental illness who claimed he was receiving inadequate treatment. Law professor and mental health advocate Michael L. Perlin has perpetuated the term in legal literature, writing extensively about it since the 1980s. American activist and educator in the psychiatric survivor movement Judi Chamberlin coined the term mentalism in her book On Our Own: Patient Controlled Alternatives to the Mental Health System, published in 1978. Neither sanism nor this definition of mentalism appears in the Oxford English Dictionary (OED).

I strongly prefer sanism, not least because mentalism already carries meaning in many other contexts, including:

  • the performing arts, where it refers to a magic trick or illusion that makes the performer appear to have extraordinary mental abilities;
  • philosophy, where it refers to the doctrine that objects of knowledge exist only in the mind; and
  • psychology, where it refers to areas of study that focus on mental perception, in contrast to behaviourism.

And with mentalist gaining a foothold in pop culture within the name of a long-running TV show, calling out discriminatory behaviour as mentalist would be confusing.

Ableism (attested in the OED in 1981—thus a more recent coinage) has been used to describe discrimination against people with disabilities, including cognitive disabilities, but because mental illness doesn’t necessarily lead to disability, I see value in distinguishing between ableism and sanism.

Embracing the use of sanism in our everyday language lets us better acknowledge the many parallels between it and other isms (or –isms masquerading as phobias).

Islamophobia and sanism compared

Whenever we hear of an individual committing an act of mass violence, it seems we’re eager to pigeonhole them into one of two categories: Muslim or mentally ill (or sometimes both, as in the case of Michael Zehaf-Bibeau). Muslims are all too aware of our knee-jerk reaction to point the finger at Islamic extremists for all acts of terror. From a Washington Post story after the 2013 Boston Marathon bombing:

As a Libyan Twitter user named Hend Amry wrote, “Please don’t be a ‘Muslim.'” Her message was retweeted by more than 100 other users, including well-known journalists and writers from the Muslim world.

Jenan Moussa, a journalist for Dubai-based Al-Aan TV, retweeted the message “Please don’t be a ‘Muslim'” and added that the plea was “The thought of every Muslim right now.” Moussa’s message was forwarded more than 200 times.

When the perpetrators turn out not to be Muslim, the public is eager find out what kind of mental illness they must have had. Anders Behring Breivik, the Norwegian gunman who took 77 lives in 2011, was branded a paranoid schizophrenic following an initial court-ordered psychiatric review, and although a later review concluded he that did not have schizophrenia, the first diagnosis still made its way into articles and books, often with no corrections or retractions. When Germanwings co-pilot Andreas Lubitz deliberately crashed his plane into the French Alps, killing all 150 people aboard,

[t]he incident sparked headlines such as “Madman in the cockpit” from the Sun newspaper, “Killer pilot suffered from depression” from the Daily Mirror, and “Mass-killer co-pilot who deliberately crashed Germanwings plane had to STOP training because he was suffering depression and ‘burn-out’” and “Why on earth was he allowed to fly?” from the Daily Mail.

These headlines, as Ingrid Torjesen wrote in a BMJ feature, fuel stigma that could prevent people from seeking help for mental health problems.

Our rush to classify terrorists as either Muslims or mentally ill is misguided in both cases. According to a 2014 Europol report, only 2% of all terrorist attacks were committed by people motivated by Islamic extremism. Similarly, according to an Institute of Medicine report, Improving the Quality of Health Care for Mental and Substance-Use Conditions,

roughly 3–5 percent of violence in the United States could be attributed to persons with mental illnesses. Moreover, results of studies from England and New Zealand indicate that in those countries, the percentage of homicides accounted for by persons with major mental illnesses has fallen in recent decades despite policies of deinstitutionalization that have placed more people with severe mental illnesses in the community. Data also suggest that most violence committed by persons with mental illnesses is directed at family members and friends rather than at strangers and tends to occur in the perpetrator’s or the victim’s residence rather than in public places… Thus, while there may be a causal relationship between mental illnesses and violence, the magnitude of the relationship is greatly exaggerated in the minds of the general population.

In fact, people with mental illness are far more likely to be victims of violence: a 2012 meta-analysis of observational studies found that adults with a mental illness were 3.86 times as likely to be on the receiving end of violence compared with adults with no disability.

Automatically attributing mass violence to people with mental illnesses is sanist, completely analogous to the Islamophobia that columnists and advocacy groups are becoming quicker to condemn.

Homophobia and sanism compared

A systematic review by UK researchers revealed that lesbian, gay, and bisexual people were twice as likely to attempt suicide in their lifetime, compared with heterosexual people. Researchers at Columbia University, however, found that for lesbian, gay, and bisexual youth

the risk of attempting suicide was 20% greater in unsupportive environments compared to supportive environments. A more supportive social environment was significantly associated with fewer suicide attempts, controlling for sociodemographic variables and multiple risk factors for suicide attempts, including depressive symptoms, binge drinking, peer victimization, and physical abuse by an adult (odds ratio: 0.97 [95% confidence interval: 0.96 – 0.99]).

Among those who are transgender or gender non-conforming, 41% attempt suicide sometime in their lives, according to the National Transgender Discrimination Survey. However, “A supportive environment for social transition and timely access to gender reassignment, for those who required it, emerged as key protective factors,” according to UK researchers.

In other words, homophobia and transphobia exacerbate suicide risk.

Mental illness, particularly mood disorders and substance misuse, is also associated with an increased suicide risk. Risk and Protective Factors for Suicide and Suicidal Behaviour, a 2008 literature review funded by the Scottish government, reported that among the 894 cases of suicide they studied, “the majority of cases (88.6%) had a diagnosis of at least one mental disorder. Mood disorders were most frequent (42.1%), followed by substance-related disorders (40.8%).” It also reported that “risk of dying by suicide in those diagnosed with schizophrenia as 4.9%,” compared with 0.010% to 0.015% in the general population. However, as Simon Davis reports in Community Mental Health in Canada, “often [suicide] occurs not in response to symptoms, such as command hallucinations, but when the individual is seeing reality clearly and facing (apparently) a future of diminished prospect and social rejection.”

Much like homophobia and transphobia, sanism—including self-stigma—exacerbates the suicide risk among people with mental illness.

Racism and sanism compared

In the wake of incidents of police violence against members of the black community in the United States, including the deaths of Michael Brown in Ferguson, Missouri, and Eric Garner in New York, activists in and around the #BlackLivesMatter movement have worked to expose the myriad ways racism has become institutionally entrenched:

  • Poverty: U.S. Census Bureau data show that in 2010, 27.4% of black Americans lived in poverty, compared with a national average rate of 15.1%.
  • Unemployment: The Bureau of Labour Statistics shows the unemployment rate of black Americans hovering at around 10%—double that of white Americans.
  • Health disparities: According to a Centers for Disease Control brochure, African Americans are 25.4% more likely to die of cancer, twice as likely to die of diabetes, and 30.1% more likely to die of heart disease and stroke, compared with white Americans. Black Americans have a life expectancy 3.8 years lower than white Americans.
  • Involvement with the criminal justice system: According to statistics from the U.S. Department of Justice from 2009, although African Americans make up only 13% of the U.S. population, they make up 40% of the male inmates in correctional institutions. A 2013 report on racial disparities in the U.S. criminal justice system, submitted to the United Nations, stated that “one of every three black American males born today can expect to go to prison in his lifetime.”

People with mental illness experienced a history comparable to that of black Americans, with segregation manifesting as institutionalization, and they are overrepresented in the same contexts:

  • Poverty: Poverty is both a cause and a consequence of mental illness. A 2013 U.S. study found that having a person with a severe mental illness in your household increases your risk of poverty three-fold.
  • Unemployment: According to the Canadian Mental Health Association,

The unemployment rate of persons with serious mental illness reflects these obstacles and has been commonly reported to range from 70–90%, depending on the severity of the disability. These statistics are particularly disturbing in light of the fact that productive work has been identified as a leading component in promoting positive mental health and in paving the way for a rich and fulfilling life in the community.

  • Health disparities: People in poor mental health are also likely to be in poor physical health. A combination of psychiatric medications that increase the risk of metabolic syndrome, lifestyle, and socio-economic factors contribute to a mortality ratio six times that of the general population. People with serious mental illness can expect to live 15 to 20 years less than people without a mental illness.
  • Involvement with the criminal justice system: According to a 2006 U.S. Bureau of Justice Statistics report, people with mental illness represent “56% of State prisoners, 45% of Federal prisoners, and 64% of jail inmates.” The National Alliance for the Mentally Ill’s 2003 survey found that 44% of people with a serious mental illness will have had dealings with the criminal justice system.

Much like systemic racism, sanism may take the form of subtle “microaggressions” that contribute to general oppression. Discrimination is common even among healthcare professionals, which can help reinforce the status quo.

Sanism in our language

"Insane" or "insanely" appears in four of the six articles on the front page of Cracked.
“Insane” or “crazy” used in four of the headlines on the front page of on May 9, 2015.

Advocates of inclusive and conscientious language use have campaigned to raise awareness of sanism in our communications, suggesting the best ways to write about suicide, for example, and encouraging writers to use “people first” language (that is, “people with a mental illness” rather than “mentally ill people” or, worse, “the mentally ill”). These same guidelines often recommend that people avoid using stigmatizing words like crazy or psycho, but these terms have so become a part of our daily language, not to mention popular culture, that eradicating them from general use is unrealistic.

Idiot, lunatic, and insane were once clinical or legal terms, but they’ve all had their turn on what psycholinguist Steven Pinker calls the euphemism treadmill, where a term becomes more and more corrupted semantically until a new euphemism is needed to take its place. They’ve also lost much of their clinical meaning with widespread use.

These kinds of broad umbrella terms used to describe mental illness may be hard to contain, but where we can make headway is in educating the public to avoid using names of specific mental illnesses to describe personal quirks, as Miley Cyrus did in a 2010 interview, saying, “I’m kind of bipolar in my acting choices because I just want to do a little bit of everything.” In a recent Vanity Fair article, Saturday Night Live alum Will Forte claimed to be “a little OCD” about his shampoo routine, a usage that has also been criticized.

The most difficult sanist language to sanitize may be terms describing substance misuse: we derisively throw around words like junkie, crackhead, and wino without a second thought. Until policy makers fully acknowledge that drug use should be a medical rather than a legal issue, we may find these loaded descriptors hard to eliminate.

A call to action—and articulation

It’s high time sanism entered the mainstream. I call for everyone (and especially journalists, bloggers, and mental health advocates) to look out for it, name it when you see it, and condemn it. Only when we end the stigma will people with mental illness feel comfortable seeking the help they need to keep themselves—and the rest of us—safe.