Identifying and Overcoming Mentalism Coni Kalinowski, M.D.

and Pat Risser InforMed Health Publishing & Training

Mentalism is a term oined b! author and a ti"ist #udi Chamberlain to des ribe dis rimination against $eo$le who ha"e re ei"ed $s! hiatri treatment %&'. (ike other )isms,) su h as ra ism and se*ism, mentalism is hara teri+ed b! om$le* so ial ine,uities of $ower that result in the $er"asi"e mistreatment of $eo$le who ha"e been labeled )mentall! ill.) -ome of this mistreatment is blatant, su h as being stri$$ed and lo ked in a old room or being beaten during $h!si al restraint. Howe"er, like all dis rimination, mentalism is e"en more ommonl! e*$ressed in the multi$le, small insults and indignities that the labeled $erson suffers e"er! da!. Dr. Chester Pier e, an .fri an/.meri an $s! hiatrist and author writing about ra ism, termed these small atta ks )mi ro/aggressions) %0'. Indi"idual mi ro/aggressions tend not to be $owerful in themsel"es. To understand their im$a t u$on $eo$le, one must onsider that the $erson is sub1e ted to hundreds or e"en thousands of these denigrating, disres$e tful ommuni ations ea h da! o"er !ears. These mi ro/aggressions ha"e a umulati"e effe t. In the 2-, we are onstantl! surrounded b! derogator! language regarding $s! hiatri $roblems %)He3s a basket ase.) )4ou3re nuts.) )5hat a loon! tune.)', negati"e stereot!$es about an!one who seeks mental

health ser"i es, hostilit! %)The! need to be lo ked u$.)', and sensationalisti media stories de$i ting $eo$le as ra+ed killers and )dangerous mental $atients). 6"er time most $eo$le annot hel$ but be affe ted b! this barrage of abuse. Man! $eo$le who ha"e e*$erien ed $s! hiatri treatment internali+e these negati"e attitudes and begin to feel badl! about themsel"es %7,8,9'. Peo$le ma! feel ashamed or blame themsel"es for their diffi ulties, feel worthless and ho$eless about their futures, or lose onfiden e in their abilities. 6ften, $eo$le find that the! must hide their histories, and li"e in fear of losing their 1ob, their friends, or their redibilit!. These rea tions to dis rimination an be ome de"astating to $eo$le as the! begin to dire t more and more of their anger and hel$lessness ba k at themsel"es. 2nfortunatel!, in the field of mental health, we rarel! re ogni+e or a knowledge the $ower of mentalism. Instead, the $erson who is demorali+ed b! his or her treatment as a )mental $atient) is more likel! to be rediagnosed, labeled )treatment resistant,) or offered more medi ation. . mental health $rofessional will rarel! address the issue of dis rimination as a fo us of ser"i es, and often, we are more likel! to ontribute to the $roblem than to hel$. Those of us who $ro"ide mental health ser"i es are ertainl! not free from the influen e of mentalism. 6ffensi"e and in1urious $ra ti es are integrated into e"er!da! lini al $ro edures to the $oint where we no longer re ogni+e them as dis rimination and find it strange that an!one should ,uestion our a$$roa h. 4et these unintentional mi ro/ and ma ro/aggressions are no less damaging to the $eo$le we ser"e. 5e are also sub1e t to the influen es of

mentalism in the sense that if we tr! to hange our mentalist attitudes or those of our fellow $ra titioners we ma! find that we are ,uestioned, hallenged, s$urned and e"en disdained. It is alwa!s un$leasant to dis o"er that we ha"e been a ting to o$$ress others. It is e,uall! un omfortable to onsider relin,uishing $ower to others. Howe"er, if we trul! want to hel$ $eo$le to re o"er and heal, we must address the im$a t of mentalism u$on their health and well/being. 5e need to do e"er!thing $ossible to eliminate mentalist $ra ti es from our ser"i es. To trul! ombat mentalism we must mo"e be!ond su$erfluous hanges that make us sound $oliti all! orre t. 5e need to earnestl! hallenge our own assum$tions and attitudes in order to $ersonall! re o"er from the $re1udi es we ha"e learned. Us vs. Them Mentalism, like all the )isms,) se$arates $eo$le into a $ower/u$ grou$ and a $ower/down grou$. In the ase of mentalism, the $ower/ u$ grou$ is assumed to be )normal,) health!, reliable, and a$able. The $ower/down grou$, om$osed of $eo$le who ha"e re ei"ed $s! hiatri treatment, is assumed to be si k, disabled, ra+!, un$redi table, and "iolent. This bla k/and/white st!le of thinking is referred to in $s! hod!nami literature as )s$litting.) -$litting $a"es the wa! to establish a lower standard of ser"i e to the $ower/down grou$. .n a$artment that is too run down for )us) is good enough for )them.) -ide effe ts that )we) would ne"er tolerate should not interfere with )their) om$lian e. Medi ation risks that )we)

find una e$table are reasonable for )them.) )5e) need redit ards to e*tend our salaries, but )the!) need to budget their so ial se urit! in ome to the $enn!. The assum$tions of mentalism are further re ruited to 1ustif! these ine,uities, as for e*am$le, )for ing 3them3 to take medi ations that ause tardi"e d!skinesia is ne essar! be ause 3the!3 are si k and 3we3 are not.) Mentalism, like ra ism, is also used to 1ustif! "iolen e. If )we) were 1um$ed u$on b! a grou$ of $eo$le, taken down and for ibl! in1e ted with $owerful medi ations, then lo ked u$ and tied down in isolation, it would be onsidered assault and batter!, kidna$$ing, or torture. If we do this to )them) in a hos$ital, it is )treatment) for their own good. Mentalist s$litting also allows the $ower/u$ grou$ to 1udge and reframe human beha"iors in a ord with the $ower d!nami . The beha"iors of the $ower/down grou$ are framed in $athologi al terms while the same beha"iors are e* used or e"en "alued in members of the $ower/u$ grou$. :or e*am$le, a $s! hiatrist olleague who threw abusi"e tantrums at nursing staff was seen as )authoritarian) and )running a tight shi$) while $eo$le re ei"ing are on the same unit were for ibl! medi ated and se luded for the same )ina$$ro$riate) beha"ior. 6f ourse, we all know from $ersonal e*$erien e that most $eo$le don3t fit into either of the artifi ial e*tremes reated b! s$litting. Most of us ha"e good and bad $eriods in our li"es, times of good and bad 1udgment, strengths and weaknesses, and $eriods of distress and of health. Rather than a knowledging that s$litting is a distortion of realit!, mentalist thinking has led $eo$le to establish a ategor! that we would all )almost us); "high-functioning."

The )high/fun tioning $atient) is generall! a $erson who is 1ust like )us) in e"er! wa! e* e$t one / his or her $s! hiatri label. The $ower/u$ grou$ an feel gratified that the! ha"e re ogni+ed the $erson3s ontributions b! a knowledging that the $erson isn3t )1ust one of them,) !et the $erson retains his<her autionar! label and all the negati"e stereot!$es that go with it. 6ther indi"iduals are gi"en the designation )low-functioning) whi h learl! on"e!s the $er e$tion that the $erson does not make "aluable ontributions and is onsidered to be of lower worth to the ommunit! %='. .t times the )low fun tioning) label an be used $uniti"el! to des ribe a onsumer who hallenges the $ower of the staff. )About twenty years ago, I'd been hospitalized several times for suicide attempts. My initial diagnosis was schizophrenia but, that changed each time I saw a different doc or therapist. he diagnosis also changed depending upon what the insurance companies were li!ely to pay for at any given time. I'd ta!en and tried most of the psychiatric drugs available at the time. I'd been in and out of day treatment several times. he day treatment I was in at the time was changing. hey were going to create two new levels. "ne level would be for the "high functioning" and the other would be a longer term, more elementary program for the more hopeless cases who were designated "low functioning." I fell into the latter group because I had the audacity to challenge one of the therapists. "f course, in every hospital and in every treatment program in which I'd participated, there was the same old worn out standard fare. hey would have groups which included stress management, assertiveness, recreational therapy #$ % also !nown as play time and of course, occupational therapy #" % which is another name for ceramics and other useless arts and crafts sorts of activities. "ne day, I'd grown bored with hearing the same thing repeated in eight wee! 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. &aturally, this upset the poor fellow and in

his flabbergasted state, he accepted my challenge. 'e 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. (lustered, 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. (rom that day forth, I was !nown 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." -).$. (abeling someone as either high/fun tioning or low/fun tioning has no healing im$a t u$on the $erson in distress and in fa t, an ha"e ,uite the o$$osite effe t. It an ause them to feel more ho$eless and hel$less and thus iatrogeni all! more distressed than before being labeled in this $e1orati"e wa!. The umulati"e effe ts of this sort of mi ro/aggression an e"en ost li"es. "*nbe!nown to the staff, we clients tal! a lot. +e tal!ed before groups, we tal!ed after groups, we tal!ed before day treatment, we tal!ed after day treatment, we tal!ed during lunch. "ne friend named Mar! had a drin!ing problem. 'e was also on some very heavy duty neuroleptic drugs. *sing all the "senior client" influence I could muster I warned Mar! of the dangers of doing both the drugs and alcohol. +ith the added influence of the others in the program, Mar! stopped drin!ing. ,taff had their own impression of Mar!. Mar! was bored with day treatment. 'e'd sit in the bac! of the room with his arms folded across his chest and never say a word. 'e was labeled "low functioning" also. After he stopped drin!ing, Mar! was very alive and animated among us mental patients. 'e'd come in every day and boast that he had gone another day without a beer. Mar! was especially eager to let us !now on Monday's that he'd managed to go a whole wee!end without a drin!. +e were very proud of Mar!. +e saw his great sense of humor and his enthusiasm for life. ,taff on the other hand saw none of this. All they saw was the same old Mar!, sitting in the bac! of the room with his arms folded across his chest.

At my wee!ly appointment with my therapist, I was told of a brand new program to train consumers to wor! as case manager aides. ,he as!ed if I was interested. I could barely contain my e-uberance. "f course I was interested. I'd be interested in anything to get me out of the drudgery of day treatment. he ne-t day, I applied and was accepted to this revolutionary program. It was the first of it's !ind in the country. I leapt into the program with all the enthusiasm I could muster. I'd never loo! bac! at the day treatment program. 'A$*M)'. /all me "low functioning" would they0 I'd show them. oward the end of the eight wee! training program, I got a call from a friend in the day treatment program. hey informed me that Mar! was dead. I as!ed what happened. It seemed that Mar! got despondent about being placed in the "low functioning" group and started to drin! again. 'e grew more and more desperate. 'e went to the staff and as!ed for help. 'e begged them to intervene. hey 1ust sort of chuc!led at him. hey hadn't seen him get better without the booze and they hadn't seen his deterioration when he returned to drin!ing. All they saw and !new of Mar! was that he sat in the groups, in the bac! of the room, with his arms folded across his chest, in silence. Mar! had tried desperately to get ahold of me in his final wee! of life. 'e felt that because I'd once stood up to the staff, I could ma!e them listen to his pleas for help. (inally, in one last act of desperation, he went home, downed a twelve pac! and pulled the trigger, blowing his brains out. I was devastated. I felt consumed with anger at the staff. I wanted to grab them all by the throat and sha!e some sense into them. 2ut, with time, my anger changed. I also grew angry with the other clients. +hy hadn't they spo!en up for Mar!0 (or that matter, why couldn't Mar! spea! up loudly enough for himself0 Mar!'s parents 1ust wanted more drugs for Mar!. hey didn't understand either. (inally, it became clearer to me. I was disgusted with what I witnessed in day treatment. I saw fol!s who'd been there for many years and the system called them a "success" because they had learned to comply with ta!ing the drugs and hadn't been in the hospital recently. +hat I saw were soul-dead fol!s who did nothing but smo!e cigarettes and drin! coffee all day. I figured I could do better so I built drop-in centers. (ol!s came to the drop-in centers and guess what0 hey did nothing but smo!e cigarettes and drin! coffee. he problem was that they had been brainwashed into a dependent

state of helplessness. I !new that the problems ran deeper than 1ust getting fol!s away from the professionals. I !new that I must wor! to help clients have their own voice. &ot 1ust some wea! s3uea!y whimper but a strong and loud and clear voice. his was my first tentative awareness of micro-oppressors and the life and death conse3uences of those oppressions and that the true struggle lay in helping my fellow mental patients to overcome this brainwashing." -).$. . sim$le rule of thumb that an be used to identif! and ombat s$litting in oursel"es is to e"aluate lini al $ra ti e as if we are the re i$ient. :or e*am$le, we might ask oursel"es if we would li"e in a ertain $la e, take a medi ation, $ut u$ with a risk or side effe t, go to a grou$, or want to be talked about in a gi"en manner. If the answer is )>o, but?) followed b! an! sort of 1ustifi ation, !ou ha"e identified mentalism in $ra ti e. It is diffi ult to generate genuine em$ath! for another $erson in the $resen e of s$litting, as the s$litting d!nami itself auses us to "iew the other $erson as entirel! a$art from and unlike oursel"es. -eemingl! em$athi statements su h as )If I were in his shoes?) often obfus ate the underl!ing mentalist assum$tion that results from s$litting; )but of ourse, I ne"er will be.) -u h statements gi"e the a$$earan e that the $ro"ider is a ti"el! tr!ing to understand the $ers$e ti"e of the other $erson but, in realit!, the! often fun tion to reinfor e $er e$tions that the other $erson is different, defe ti"e, or de"iant. 6ften it is subtl! im$lied that the $erson has brought her diffi ulties on herself, or that the $erson has hosen to affe t disabilit! and ould hoose to )sna$ out of it.) It further im$lies that the om$etent $ro"ider would e*ert better 1udgment in the re i$ient3s

situation and would therefore es a$e the diffi ulties fa ing the re i$ient. The o"erall effe t is that the seemingl! em$athi statement be omes a "alidation of the su$eriorit! of the $ro"ider and an then be used to 1ustif! ine,uities of $ower and the o$$ressi"e $ra ti es that result. @e ause )being in the re i$ient3s shoes) is seen as a $urel! h!$otheti al situation, the $ro"ider an 1ustif! gi"ing it little serious intros$e ti"e onsideration and draw broad on lusions with little attention to logi . . lear e*am$le of this is the $ro"ider who asserts, )If I were homeless and mentall! ill, I would want to be medi ated in"oluntaril!) as a 1ustifi ation for out$atient ommitment for others. Rarel! do these indi"iduals ha"e ad"an e dire ti"es for themsel"es stating this $referen e, as the! would if their omment was made in earnest. The! learl! see homelessness and $s! hiatri disabilit! as unlikel! to o ur in their li"es and ha"e, therefore, not seriousl! onsidered the om$le* so ial and $ersonal barriers that the! might fa e in that situation. Their $seudo/em$ath! be omes a $latform for $romoting so ial ontrol rather than an! true understanding of $eo$le3s diffi ulties and needs. It also reinfor es the $ower differential between $ro"ider and onsumerA the $ro"ider3s imagined e*$erien e of homelessness and $s! hiatri disabilit! is gi"en more redibilit! than the onsumer3s a tual e*$erien e with these hallenges. Ideall!, we should treat $eo$le as we would want to be treated, with res$e t, dignit!, and on ern. 5e should listen to $eo$le and $ro"ide ser"i es based u$on their e*$ressed interests instead of 1udging them and a ting in what we %$erha$s falsel!' belie"e to be their best interests. 5e should ne"er refer $eo$le to an! ser"i e or

resour e that we would not use oursel"es, or sub1e t an!one to treatment that we would not wel ome for oursel"es. This is a loft! goal in a so iet! that ontinues to $ro"ide inade,uate $ubli su$$orts and resour es for $eo$le3s basi needs. 2ndoubtedl! most lini ians will find themsel"es in the $osition of making less/than/o$timal referrals. B"en in the fa e of these diffi ulties, we an ommuni ate on ern for the omfort and $referen es of the $erson we are ser"ing, and affirm the $erson3s deser"edness of a better life. It is "er! im$ortant that we not on"e! the im$ression that $eo$le must a e$t substandard treatment, or should be grateful for whate"er the! are gi"en. 5e need to e*$ress ho$e that the $erson will a hie"e the ,ualit! of life that s<he desires and offer assistan e to hel$ the $erson to im$ro"e his or her ir umstan es. 5e also need to en ourage $eo$le to ho$e and dream. Too often, we tell $eo$le what the! an3t do and thus, we rob them of the abilit! to ho$e. Instead, we need to hel$ $eo$le to find within themsel"es both the abilit! to dream and the belief that those dreams an be ome $ossible. 5e an ommuni ate aring and res$e t b! retaining a "ision of $eo$le3s strengths and "alue e"en during the bad times, and en ouraging them alwa!s to draw u$on their better ,ualities and abilities. Distinguishing What We Think From What We Know :or the most $art, humans tend to belie"e the! know a lot more than the! a tuall! do. Most of what we think we know is a tuall! belief in a model or an a$$ro*imation, and "er! often these models $ro"e to be false. Consider, for e*am$le, the $eo$le who re"iled -emmelweis

and Pasteur be ause the! !new that mi robes ould not e*ist, or the In,uisitors who $unished Calileo for belie"ing in anti/s ri$tural Co$erni anism that stated that the sun was the enter of the solar s!stem and that the $lanets re"ol"ed around the sun. (ike them, we an e*$e t that most of what we ha"e learned in $rofessional training will similarl! be re$la ed b! different models and new information. >ew learning is further om$li ated b! the length of time that trans$ires between resear h and im$lementation. 2nfortunatel!, in the human ser"i es realm, that length of time is "er! long, on the order of ten or more !ears. -o, while resear h has onfirmed the benefits of onsumer hoi e in the healing $ro ess, $rofessionals generall! ontinue to $ro"ide ser"i es that fo us on onformit! and om$lian e. Due to this lag between resear h and $ra ti e, $eo$le using ser"i es will not ha"e the benefit of ontem$orar! a$$roa hes that address the effe ts of mentalism for man! !ears and $ra titioners will ontinue to im$lement ser"i es that are alread! outmoded and are fre,uentl! in1urious. :or these reasons, we must de"elo$ a dee$ a$$re iation for how mu h we don3t know, and a$$roa h our work with ommensurate humilit!. If we are honest, we must admit that we don3t know wh! $eo$le ha"e the e*$erien es that are labeled )$s! hiatri ) or whether these are a tuall! illnesses. 5e don3t know how medi ations affe t $eo$le. 5e don3t know how neuro hemistr! relates to human feeling and beha"ior. 5e don3t know how $eo$le re o"er and heal. This is not to sa! that mental health $rofessionals ha"e nothing to offer $eo$le. 5e ha"e useful information, resour es, and "arious treatment a$$roa hes. 5e an also offer the one thing that

onsumers identif! as an essential fa tor in re o"er!; a su$$orti"e, res$e tful, genuine hel$ing relationshi$. "In all the times I was hospitalized, both voluntarily and involuntarily, I never received any help through the drugs, the seclusion, the restraints, the impersonal structure of the day, the "milieu," the worn out tired old "same 'ole, same 'ole" groups or any of the other staff imposed routine. he "&45 thing that ever helped me was face-to-face, person-to-person contact with caring individuals. "nly rarely did any staff person ever even attempt to ma!e that sort of connection. More often than not, those caring individuals were my fellow patients. hose caring connections were literally what !ept me sane in insane places and were the only thing that produced any healing effect. It's why I went on to form effective self-help groups outside of the hospital. I realized that the healing benefits come from other people and not within the structure of the institutions." -).$. Mentalist thinking often auses us to lose sight of the ga$ing holes in our knowledge and to underestimate our limitations. 5e begin to belie"e that we ha"e sound s ientifi answers for $eo$le3s $roblems and that the treatment we re ommend is )right.) :ailure to re ogni+e the limits of our knowledge an lead us to a t $rematurel! and restri ti"el!. 5e tend to inter$ret beha"ior when we should in,uire about its meaning, and $res ribe inter"entions when we should listen and learn. "I used to sit under a bridge and bang the bac! of my head on the concrete until the bac! of my head was a bloody mess. he typical mental health wor!er would, upon observing this, panic and forcibly intervene. his intervention would be predicated upon the belief that I was too "out of it" to !now what I was doing. 'owever, both my personal e-perience and that of most mental health consumers I've tal!ed with cause me to believe that even though we may appear to be "out of it," we are still connected on some level. I 6&7+ I was banging my head and could have even tal!ed with

someone about that fact if anyone had ta!en the time to attempt to communicate with me. A good friend, sums this up by saying, "1ust because I'm banging my head on a table doesn't mean I don't !now that I'm banging my head on a table." Most professionals won't listen to us and learn that even in our worst "psychotic state" they could still connect with that part of us which still has a level of awareness if they'd only try. It seems easier for them to 1ust assume we're totally "out of it" and to impose their will forcibly upon us in the name of help." -).$. T!$i all!, when treatments are ineffe ti"e or una e$table, the re i$ient is blamed. He or she is )treatment/resistant,) )un oo$erati"e,) )non/ om$liant,) or ) hara terologi ) and has therefore failed the $ro"ider rather than the other wa! around. -<he ma! e"en be $ressured, threatened, or oer ed to a e$t the treatment, des$ite the fa t that it has alread! $ro"en to be inade,uate. This is $arti ularl! ommon in the ase of the $erson who refuses a $s! hotro$i medi ation due to side effe tsA lini ians often insist u$on ) om$lian e) des$ite the $erson3s e*$erien e of $h!si al dis omfort, neurologi al im$airment, or other e"iden e that the treatment is not effe ti"e. To ombat this mentalist $re1udi e, we need to modif! our assum$tions and a$$roa h $eo$le in a manner that a knowledges the im$erfe tions of our tools. The re i$ient3s la k of res$onse or ob1e tions to the treatment must be assumed to be reasonable and redible. 5hen treatment fails, it is always due to the shortcomings of the treatment. These short/ omings ma! in lude inade,uate understanding of the $erson or his<her $roblems, medi ation side effe ts, $oor mat h between the treatment and the $erson3s lifest!le, stigma asso iated with the treatment, diffi ult! with a ess, ultural

una e$tabilit! or man! other issues. It is the lini ian3s res$onsibilit! to initiate the res$onse to treatment failure in a ollaborati"e manner b! talking with the $erson re ei"ing the ser"i e. These dis ussions should e*amine the diffi ulties with the treatment and e*$lore wa!s that it an be modified to better fit with the $erson3s needs. Mentalism in anguage Mentalism is elo,uentl! e*$ressed in the 1argon of mental health, whi h dire tl! refle ts the $ower differen e that e*ists between the )$ower/u$) and the )$ower/down) grou$s. Changing our language alone will ertainl! make us less offensi"e to others and gi"e the a$$earan e of being $oliti all! orre t. Howe"er, to trul! address the issue of $re1udi e and ha"e an im$a t on our $arti i$ation in dis rimination, it be omes ne essar! to look at the attitudes and assum$tions underl!ing the words. The language that has be ome $oliti all! harged in mental health in ludes terms that ommuni ate ondes ension, blame, and the $er e$tion of labeled $eo$le as defe ti"e. Man! offensi"e terms are ob"ious / basket ase, loon! tune, et . The offensi"e as$e ts of seemingl! $rofessional terminolog! are often more subtle. How these terms are used from an inter$ersonal or s!stemi stand$oint is generall! more im$ortant than their o"ert meaning. Interestingl!, mental health $rofessionals often ob1e t that the! )need) these words to ommuni ate $s! hiatri on e$ts. 4et most of the offensi"e terminolog! is non/medi al and non/s$e ifi , and ould easil! be e*$ressed in a more a urate, less offensi"e manner.

. good e*am$le is the term decompensate whi h is used ollo,uiall! to indi ate that a $erson is ha"ing more distress. It does not refer to a s$e ifi lini al finding, s$e trum of s!m$toms, or e"ent, so that the lini ian who is referred a $erson who )de om$ensated) knows nothing about the $erson3s needs or histor!. Inter$ersonall!, the term is generall! used to designate someone who is defe ti"e and fragile, who annot take are of him/ or herself, and who annot tolerate stress and therefore falls a$art. )De om$ensating) is an us/ them termA under stress )we) ma! not do wellA )we) ma! o oon, take to bed, get bummed out, get burned out, get a short fuse, throw $lates, s ream, all in si k, or need a lea"e of absen e. )The!) decompensate. 6 asionall!, the term is used with an o"ertone of su$eriorit! that is learl! intended to on"e! the $ower differen e between the ) om$etent $rofessional) and the )si k lient.) @oth a ti"ists and lini ians ha"e suggested that $eo$le abandon this term in fa"or of des ribing, briefl! but a uratel!, what the $erson is e*$erien ing. :or e*am$le, ).fter the break/u$ with her girlfriend, Mar! ouldn3t slee$. -he started $a ing at night and om$lained of hearing "oi es.) This brief statement fa tuall! des ribes Mar!3s e*$erien e and gi"es meaningful information that begins to suggest inter"entions that ma! be hel$ful. Man! a ti"ists ha"e noted that $art of the demotion from )us) to )them) is a loss of one3s designation as a $erson. 6ne is suddenl! no longer a $erson with a diagnosis, but )a s hi+o$hreni ) or )a bi$olar.) Peo$le who ha"e internali+ed this dehumani+ing labeling $ro ess will e"en at times introdu e themsel"es as )a mental $atient) or )a CMI) %) hroni all! mentall! ill)' rather than introdu ing themsel"es b! name.

Professionals who are entren hed in this terminolog! will often ounter that this is no different than referring to a $erson as )a diabeti .) Howe"er, it is im$ortant to fa tor in the realit! that medi al illnesses are not asso iated with the negati"e assum$tions and $re1udi es that are inferred from a $s! hiatri label. . )diabeti ) is not assumed to be "iolent, un$redi table, or in om$etent. The dehumani+ing as$e ts of $s! hiatri diagnosis ombined with the traumati e*$erien es that man! $eo$le ha"e had under $s! hiatri treatment ha"e aused $eo$le to asso iate the term )$atient) with dis rimination, oer ion, and o$$ression %D, E'. 2nlike the $atients of a dentist, o$tometrist, or g!ne ologist, the $s! hiatri )$atient) is often for ed to ha"e treatment, in ar erated against his or her will, and stigmati+ed for life. In a ti"ist ir les, the term a$$lied to a $erson who has re ei"ed $s! hiatri treatment has be ome a "er! $ersonal hoi e that refle ts the indi"idual3s e*$erien es, feelings, and identit!. Indi"iduals ma! hoose to refer to themsel"es as e*/$atients, sur"i"ors, onsumers, or lients, or the! ma! refuse a designation altogether. Ci"il rights/oriented grou$s often refer to ) onsumers<sur"i"ors<e*/$atients,) while the designation ) lient) remains the most ommon and generall! a e$ted term in $ubli mental health s!stems. Man! $eo$le in the medi al ommunit! ha"e been o"ertl! resistant to hanging their terminolog!, and e,uall! resistant to onsidering the trauma that underlies the mo"ement for hange. Ps! hiatrists and nurses seem $arti ularl! unwilling to e*amine the ruelt! and betra!al e*$erien ed b! the $eo$le who ha"e been mandated to $s! hiatri are. Most indi"iduals who ha"e had a long/

standing $s! hiatri disabilit! an re all for ed BCT without anesthesia, $h!si al or se*ual abuse b! staff, being taunted or humiliated, being sha kled to a bed, in"oluntar! lobotom!, or being sub1e ted to $ainful )beha"ior thera$!.) . olleague of the authors e"en re$orted that he remembered being herded into a mass shower with a attle $rod while he was a $atient at the state hos$ital. Bfforts to $rote t the rights of indi"iduals ha"e eliminated some, but ertainl! not all, of these in1urious $ra ti es. It is the $ain and the fear generated b! these e*$erien es that underlies the mo"ement to find new terms and on e$ts. It is ho$ed that a hange in language will ontribute to a hange in assum$tions and attitudes that will in turn deter su h abuses and unders ore the need to $reser"e a $erson3s safet!, libert!, and dignit!. 4et, mu h like the $erson who 1ustifies the use of ethni slurs be ause s<he intends no harm, medi al $ersonnel ha"e ontinued to 1ustif! the use of the term )$atient) be ause the! see it as sim$l! te hni al. 6thers defend its use be ause it re$resents a sa red trust between do tor and $atient. These seemingl! reasonable and noble e*$lanations are a smoke s reen for the mentalist $ower d!nami ; $rofessionals are generall! a ustomed to being in harge and, as a olleague on e said, the!3re )not about to be di tated to b! a bun h of $atients.) Consistent with the $ower d!nami , the $ower/u$ grou$ is omfortable with the e*isting terminolog! and that omfort takes $re eden e o"er the feelings, well/being, and dignit! of those who are $ower/down. Most of the time, $rofessionals ause these offenses unintentionall!, but this makes them no less wounding. In order to

es a$e from mentalist attitudes and language we need to e*amine the underl!ing meanings and fun tions of our ommuni ations. :or e*am$le, if I des ribe someone as )a borderline with intense de$enden !,) )a non/ om$liant s hi+o$hreni ,) )an o$$ositional $atient,) )a t!$i al drug/seeking antiso ial $ersonalit! disorder,) )a mani$ulati"e, game! mani ,) am I seeking to understand, res$e t, and hel$, or merel! $ass 1udgment, feel su$erior, and assert m! $rofessional dominan eF It an be illuminating to ask oneself wh! one ontinues to use a term that offends and stigmati+es the $eo$le one as$ires to hel$. If we la k the em$ath! that would moti"ate us to hange our language to a"oid hurting the $eo$le we ser"e, what does that sa! about our integrit! as healersF Res$e tful lini al language should fo us both the lini ian and the re i$ient on the sear h for the most su essful tools for health and re o"er!. If a diagnosis hel$s a $erson to understand her<his e*$erien es and gain ontrol o"er her<his life, it is a useful tool. If it stigmati+es, ommuni ates ontem$t, and e* ludes the $erson from ser"i es, it is a wea$on. Res$e tful lini al language is not a misre$resentation or under/estimation of a $erson3s diffi ulties and e*$erien es. It should be $re ise, fa tual, and om$lete. It should also ommuni ate the $ers$e ti"e of the $erson re ei"ing ser"i es, in luding his<her "alues, interests, and $riorities. Man! indi"iduals who ha"e re ei"ed mental health ser"i es feel that the "erna ular of lini ians misre$resents realit!. "I hate that word "treatment." It's been twisted by the system and perverted beyond recognition. If they loc! you up against your will, strip you literally and figuratively #of your rights% and force you into

bondage and solitary confinement and then in1ect you with powerful and painful drugs, they call it "treatment." In every other possible realm on earth, this is torture and not "treatment." If they set a fifteenminute appointment for you to renew your drugs every two wee!s or month, they call that "treatment" and they can bill your insurance for payment. I consider it fraud." -).$. " o be a mental patient is to participate in stupid groups that call themselves therapy -- music isn't music, it's therapy8 volleyball isn't a sport, it's therapy8 sewing is therapy8 washing dishes is therapy. 7ven the air that we breathe is therapy -- called milieu. " -$ae *nzic!er #9% "&ormal behaviors are &" symptoms. &ormal people can have a bad day, an "off" wee! and even a "down" month. 'owever, if we e-hibit those normal behaviors on the 1ob, we get labeled and we are as!ed if we too! our medications or if someone needs to call our shrin!." -).$. " here is no such thing as a 'side-effect.' here are only 'effects' from ta!ing drugs. ,ome effects are desired and others are undesirable. /alling something a "side-effect" obscures and minimizes the resultant pain, suffering and misery that can be caused by psychoactive drugs and in doing so, it discounts our e-periences and perceptions and thus sets us up as less than we are. It denies our reality." -).$. . good rule of thumb to address mentalism in language is to ask oneself if !ou would use the same language when s$eaking dire tl! to the $erson or if !ou would feel omfortable ha"ing the $erson read what has been written in the hart. 6ther useful ,uestions in lude; 5ould I want to be talked about in this mannerF 5ould I talk about m! friends and olleagues in this mannerF Does this language hel$ the $erson and the lini ian to find solutions to $roblems and reate $ositi"e hangeF .n! )>o) answers, no matter how seemingl! 1ustifiable, indi ate mentalism is o$erating within the ommuni ations.

Mentalism in !rognostication Mental health $rofessionals are ommonl! alled u$on to $redi t what $eo$le will do in life and whether the! will re o"er. 5e ha"e be ome a ustomed to on"e!ing rather dire $redi tions about hroni it!, and often in harts under )Prognosis) one will see su h terms as )$oor) or )guarded.) In general, m! e*$erien e has been that mentalist assum$tions ha"e aused lini ians to ha"e a rather $essimisti "iew of the a$a it! for their lients to re o"er. Man! lini ians o"ertl! dismiss the idea that $eo$le o"er ome their diffi ulties and lea"e mental health ser"i es to ha"e full li"es. 5hen one $oints out the large number of $eo$le, in luding man! mental health a ti"ists, who ha"e o"er ome their disabilities, lini ians ommonl! res$ond that these indi"iduals must ha"e been )misdiagnosed) or )do not reall! ha"e s hi+o$hrenia.) In fa t, man! longer/term resear h studies ha"e shown that a signifi ant number of $eo$le ha"ing serious $s! hiatri on erns re o"er om$letel!, irres$e ti"e of their $resentation or diagnosis. Dr. Courtne! Harding3s studies, for e*am$le, showed that a$$ro*imatel! 9GH of $eo$le ha"ing $s! hiatri disabilities re o"ered full! o"er a 09 !ear time $eriod %&G, &&, &0'. Man! of these $eo$le re ei"ed no further treatment, in luding $s! hiatri medi ations. These obser"ations are in marked ontradistin tion to the assum$tions of most mental health $rofessionals, and man! lini ians are ,ui k to tr! to dis ount or dis redit this resear h. 5hile one an endlessl! dis$ute resear h methodolog!, the human im$a t of mentalism in $rognosti ation is undeniable. Peo$le

re ei"ing the $ronoun ements )4ou will ha"e this disabilit! for life,) )4ou will alwa!s ha"e to take medi ations,) or )4ou will not be ome a law!er<do tor<e onomist<tea her) are almost in"ariabl! de"astated. -ome e*$erien e hel$lessness and des$air. 6thers resist, refuse further treatment, or seek other alternati"e wa!s to heal. In fa t, the a ura ! of su h $redi tions is ab!smal, and re$eatedl!, studies ha"e onfirmed that the riteria that lini ians em$lo! to make su h $redi tions are not related to re o"er!. :or e*am$le, lini ians ha"e traditionall! dis ouraged $eo$le from seeking em$lo!ment on the basis of the se"erit! or fre,uen ! of their s!m$toms or the length of time the! ha"e been disabled. >one of these fa tors has $ro"en to orrelate $ositi"el! or negati"el! with su essful em$lo!mentA the best $redi tors are intuiti"el! ob"ious / moti"ation to work and a$a it! to learn %&7, &8'. 6"er oming mentalism in $rognosti ation re,uires that we riti all! e*amine our assum$tions about re o"er! from $s! hiatri disabilities. In man! instan es, lini ians3 "iews ha"e been skewed b! the fa t that the! are most likel! to see $eo$le onl! during the times when the! are e*$erien ing distress. Those who re o"er rarel! ome ba k to the lini or the hos$ital. 5e must dis lose to $eo$le that we don3t know who will re o"er, when, or how. In man! wa!s this allows us to im$art a "er! ho$eful message to e"er!one we ser"e. >o matter how $ainful a $erson3s disabilit!, no matter how in a$a itated s<he ma! ha"e been, no matter how long s<he has struggled, there is alwa!s a signifi ant han e that s<he will im$ro"e onsiderabl! or e"en re o"er om$letel!. . message of ho$e also o$ens the door for lini ians to inform $eo$le about the things the! an do to restore their

health and what $itfalls to a"oid. In our e*$erien e, $eo$le are often more moti"ated to work on their health if the! are aware that there is a reasonable likelihood of su ess. Mentalism and !sychotro"ic Medications The attitudes and $ra ti es that surround the use of $s! hotro$i medi ations are unfortunatel! full of manifestations of mentalism. In its most ob"ious form, the $erson re ei"ing treatment is $resumed to be ) ra+!) and therefore unable to make medi al de isions, so that medi al $ersonnel fail to obser"e the usual $ro edures with res$e t to informed hoi e. 6ften a $erson3s ob1e tions to medi ations are dismissed on the grounds that )mental $atients annot a$$re iate the gra"it! of their illnesses) and therefore the $erson3s e*$erien e of the treatment is deemed in"alid. It is also both unfortunate and ommon in bus! offi e $ra ti es for lini ians to gloss o"er the $roblemati side effe ts des ribed b! their lients without full! onsidering the im$a t u$on $eo$le3s li"es. The m!th of om$lian e is a $arti ularl! destru ti"e manifestation of mentalism in $s! hiatr!. >owhere in medi ine are $h!si ians more $reo u$ied with enfor ing ) om$lian e.) Most non/ $s! hiatri $h!si ians ha"e ome to a e$t that om$lian e itself is a m!th. Certainl!, studies of ) om$lian e) with e"er!thing from diabeti diets to anti/h!$ertensi"e agents show that humans don3t om$l! with an!thing. .t least one third of $eo$le in these studies fail to follow their do tors3 instru tions and man! studies ha"e shown rates of )non/ om$lian e) of o"er 9GH %&9'. -tudies of $eo$le who are ontending

with $s! hiatri disabilit! ha"e shown that the best results are obtained when $eo$le are well/informed and in ontrol of their treatment and when health are $ro"iders build fle*ibilit! into treatment regimens %&=, &D, &E'. 4et $s! hiatr! has ontinued to su$$ort measures that fo us on for ing $eo$le to om$l! with treatments that the! feel are unhel$ful. To a large degree this refle ts a ke! element in the dis rimination and mistreatment of $eo$le ha"ing $s! hiatri on erns; be ause on erns as mentalist $re1udi es $ortra! $eo$le ha"ing $s! hiatri

"iolent and un$redi table, treatment has largel! be ome s!non!mous with so ial ontrol. .s a result, mental health lini ians tend to e,uate subduing the $erson with treatmentA a ,uiet lient who auses no ommunit! disturban e is deemed )im$ro"ed) no matter how miserable or in a$a itated that $erson ma! feel as a result of the treatment. .s in other forms of so ial ontrol, in ar eration is used to ontain the $erson who will not om$l!, though, be ause the in ar eration o urs in a hos$ital, it is deemed to be )treatment.) 5hen a$$lied to other forms of medi al treatment this model sounds absurd. Imagine 1ailing a diabeti for ha"ing dessert or in ar erating a $erson ha"ing hroni bron hitis for lighting u$ a igarette or forgetting his<her inhaler. If stringent monitoring of om$lian e with general medi al treatment were enfor ed through so ial ontrol, it is fair to sa! that we would all be in ar erated o"er time. >o one would find su h a solution to $ubli health $roblems a e$table be ause it "iolates $eo$le3s right to hoose their lifest!les and medi al treatment. In "irtuall! all other medi al on erns, we ha"e u$held indi"iduals3 rights in this regard irres$e ti"e of the

$ossible risks to self or others. The onl! e* e$tion has been in the re$orting and treatment of highl! ommuni able diseases. 4et numerous legislati"e initiati"es throughout the 2- are $resentl! $ro$osing that $eo$le ha"ing $s! hiatri onditions be lo ked u$ in $s! hiatri fa ilities if the! fail to om$l! with treatment and are deemed to be at ris! of be oming ill. This learl! om$romises the rights of $eo$le ha"ing a $s! hiatri diagnosis in wa!s that we would ne"er onsider for $eo$le ha"ing medi al diagnoses. Mentalism in $s! hiatri $ra ti e is also a$$arent in the la k of thoroughness in informed onsent and in the monitoring of medi ation side effe ts. In California, informed onsent is $resentl! obtained b! ha"ing $eo$le sign a $a$er on whi h $ossible medi ation side effe ts are listed. >o distin tion is made between dangerous side effe ts and un omfortable onesA no suggestions are gi"en for identifi ation and management. 6n e signed, the information is $la ed in the hart so that the indi"idual has no a ess to it. 6ften, medi all! serious side effe ts are )dumbed down) so that $eo$le do not get an a urate "iew of the risks in"ol"ed. :or e*am$le, tardi"e d!skinesia, a $otentiall! $ermanent neurologi al ondition aused b! anti$s! hoti medi ations, is often des ribed as )ha"ing mus le ti s.) Man! $eo$le are a$$roa hed for onsent onl! during rises or a ute bouts of their onditions, and the information is ne"er re"isited when the $erson is more able to on entrate and $ro ess information. This a$$roa h to informed onsent is of minimal benefit to the $erson re ei"ing treatment. The $erfun tor! ,ualit! of this a$$roa h to informed onsent is learl! dri"en b! the mentalist $ower d!nami , whi h a ts

to $rote t the lini ian from allegations of negligen e without trul! informing the $erson getting treatment. Monitoring of side effe ts is also ons$i uousl! affe ted b! mentalist $re1udi es. . $arti ularl! worrisome e*am$le of this is the failure of man! $s! hiatrists to e*amine $eo$le for tardi"e d!skinesia %TD'. .s noted abo"e, TD is a neurologi al ondition aused b! anti$s! hoti medi ations. It is hara teri+ed b! the gradual onset of in"oluntar! mus le mo"ements that ma! in lude grima ing, ra$id blinking and s,uinting, tongue $rotrusion, mo"ements of the arms and legs, and twisting and writhing motions of the trunk. 5hen TD is dete ted earl!, it is often om$letel! re"ersible. If it is not dete ted earl!, TD is often $rogressi"e and $ermanent, so that e"en if the medi ation is sto$$ed, the $erson ma! ontinue to ha"e odd mo"ements that s<he annot ontrol. 5hen these mo"ements are se"ere, the! an interfere with sight, eating, s$ee h, walking, and other basi a ti"ities. The mo"ements are e*tremel! stigmati+ing, and an ha"e serious health onse,uen es. :or e*am$le, when TD auses in"oluntar! mo"ements of the mus les of the throat, li,uids ma! leak into the wind$i$e when $eo$le swallow, ausing re$eated bouts of $neumonia. 5hile the $erson is taking the anti$s! hoti medi ation, the mo"ements of TD are often masked. The! also ma! not be a$$arent until the $erson is distra ted or e* ited. :or all these reasons, the .meri an Ps! hiatri .sso iation re ommended in &IEG that $s! hiatrists redu e the dose of anti$s! hoti s on a regular basis and e*amine $eo$le taking these medi ations for TD annuall! using a standardi+ed assessment su h as the .IM- or the DI-C2- %&I'. Howe"er, this is not what t!$i all!

ha$$ens in mental health lini s. Cenerall!, indi"iduals taking neurole$ti s are en ouraged to sta! on a maintenan e dose of medi ations. Regular dose redu tions are rare, as lini ians fear the $erson will )de om$ensate.) Ps! hiatrists t!$i all! obser"e the $erson informall! for ob"ious in"oluntar! mo"ements and indi ate in the hart )no TD.) Rarel! is an .IM- or DI-C2- $erformed or do umented. Cenerall! the dis ussion of TD is limited to the warning of $ossible )mus le ti s) gi"en in the informed onsent. Ho$efull! it is ob"ious that these measures are inade,uate to dete t TD or address the medi al risks asso iated with it. The net result is that !ear after !ear, thousands of $eo$le re ei"e anti$s! hoti medi ations without e"er being thoroughl! e"aluated for a $otentiall! disabling medi ation side effe t. 6ne an onl! wonder wh! $s! hiatrists are failing to $erform this routine monitoring of medi ation risks. Certainl!, it is not due to time onstraints, as the modified .IM- %.bnormal In"oluntar! Mo"ement - ale' or DI-C2- %The D!skinesia Identifi ation -!stem Condensed 2ser - ale' takes onl! &G minutes to $erform and rate %0G'. It annot be due to fears that $eo$le will abandon treatment, as resear h suggests that well/informed re i$ients tend to be more in"ol"ed in their are and less likel! to be )non/ om$liant.) 6ne an onl! on lude that mentalism is o$erating here as elsewhere, ausing $s! hiatrists to feel that unidentified TD is somehow an a e$table risk for $eo$le ha"ing $s! hiatri disabilities. The om$arison with medi al maltreatment based u$on ra ism, su h as the Tuskegee e*$eriment in whi h .fri an/.meri an men were allowed to be

e*$osed to the risks asso iated with untreated s!$hilis, is ines a$able. It has been "irtuall! im$ossible to $enetrate $s! hiatri denial regarding the issue of TD, des$ite .P. re ommendations and multi/ million dollar mal$ra ti e suits. Its most re ent in arnation is the $re"alent belief that newer anti$s! hoti medi ations do not ause TD. Man! lini ians a$$ear obli"ious to the fa t that all anti$s! hoti medi ations ha"e been found to be asso iated with the de"elo$ment of TD, and that the studies showing redu ed risk with newer agents ha"e been ondu ted for relati"el! brief $eriods of time. B"en lo+a$ine, the )gold standard) among anti$s! hoti s, and the serotonin reu$take inhibitor antide$ressants ha"e been asso iated in rare instan es with this ondition %0&, 00, 07'. Ine*$li abl!, the same $h!si ians that insist u$on other earl! dete tion measures su h as blood tests, P.P smears, mammograms, and $rostate e*ams ontinue to refuse to $erform the .IM- for $eo$le taking neurole$ti s. Blimination of mentalist dis rimination in medi ation $ra ti es re,uires that we refle t on our attitudes and make signifi ant de$artures from the $resent state of $s! hiatri $ro edure. -ome suggestions follow; &. 5e must se$arate, on e$tuall! and in $ra ti e, the use of $s! hotro$i medi ations to enfor e so ial ontrol from true treatment. Ps! hiatrists are $resentl! burdened with the unrealisti so ietal e*$e tation that the! an ensure $ubli safet! through the use of $s! hotro$i drugs to ontrol $eo$le who are labeled as $otentiall! de"iant. 2ntil we are relie"ed of this o$$ressi"e m!th, lini al $ra ti e

will ontinue to refle t the $ubli 3s mentalist $re1udi es rather than the needs of the $eo$le we ser"e. 0. Informed onsent must be refined so that $eo$le re ei"e om$rehensi"e and easil! understandable information about their hoi es that neither atastro$hi+es nor down$la!s the health risks of the treatment. This information should be re"iewed with the $erson $eriodi all! and needs to go with the $erson rather than sitting in the hart. 7. 5hen making treatment de isions, we must gi"e highest $riorit! to the indi"idual3s assessment of the treatment, es$e iall! his or her sub1e ti"e re$ort of side effe ts and the im$a t of the medi ations on his<her life. 5e need to be aware of the biases of others who ma! re$ort that a $erson is )im$ro"ed) when in fa t the $erson is sim$l! too sedated or too neurologi all! im$aired b! the medi ation to ) ause trouble.) 8. 5e must abandon the m!th of om$lian e and fo us instead on understanding the de ision/making $ro esses that $eo$le go through as the! hoose their treatment. 9. 5e must diligentl! a$$l! oursel"es to the task of earl! identifi ation of the medi al onse,uen es of $s! hotro$i medi ations. This should in lude regular e*amination for TD, a$$ro$riate blood tests for li"er or kidne! damage, annual o$hthalmolog! e*ams for $eo$le taking $henothia+ine anti$s! hoti s, audiolog! s reening for $eo$le taking "al$roi a id $re$arations, and so forth. Mentalism and the !hysical #nvironment

In lini s, residen es, and in the ommunit!, mentalism an be found in the design and maintenan e of the $h!si al en"ironment. The indi ators of $ower e*$ressed in en"ironmental terms in lude s$a e, $ri"a !, safet!, leanliness, omfort, hoi e, a ess, and aestheti s. 5e all know how this works from $ersonal e*$erien e. :or e*am$le, the $erson at the to$ of an organi+ation has a large $ri"ate offi e with omfortable, or e"en la"ish, furnishings and usuall! her<his own om$uter and $rinter. The $eo$le at the bottom work in small ) ubes,) ha"e utilitarian furnishings, and share fa ilities su h as refrigerator, $rinter, om$uter, and restroom. Mentalism makes these differen es e"en more $ronoun ed. Indi"iduals li"ing in su$$orted en"ironments often share rooms with roommates not of their hoosing, rarel! ha"e $ri"a !, and use furniture that is hosen b! others for eas! maintenan e and durabilit! rather than omfort or aestheti s. Man! ha"e insuffi ient s$a e to dis$la! or store $ersonal $ossessions. Man! residen es $ro"ide no wa! for $eo$le to lo k their $ossessions, their rooms, or the bathroom to insure safet! and $ri"a ! and deter theft. 6ften, housing o$tions are run/down or lo ated remotel!, and labeled $eo$le are left to use $ubli trans$ortation that is in on"enient, un omfortable, or e"en unsafe. In man! wa!s, these onditions are shared b! an!one who has little mone!. Howe"er, mentalism does ontribute to man! s$e ifi en"ironmental mi ro/aggressions as well. . ommon one, o urring in man! lini s, is sim$l! the se$aration of staff and lient restrooms. The se$aration of the fa ilities for )staff) and ) lients) mirrors the

onditions in the -outheastern 2- $rior to the i"il rights mo"ement of .fri an/.meri ans, where ra ist beliefs led to the se$aration of all $ubli fa ilities for )whites) and )non/whites). In $ubli mental health lini s, the se$aration of fa ilities is often ombined with a la k of maintenan e and $ri"a ! in the restrooms used b! lients. In one $la e that I am aware of, stalls in the ) lient) restroom had no doors. This was 1ustified as a )safet! measure.) .s with other dis riminator! $ra ti es, lini ians often 1ustif! the se$aration of fa ilities; ) lients ha"e a different standard of h!giene than we ha"e.) Ho$efull!, the ondes ension ontained in this res$onse is ob"ious. It also obfus ates the res$onsibilit! of a $ubli ser"i e to $ro"ide a res$e tful $h!si al en"ironment for $ubli use. If $ubli use auses the fa ilit! to need more leaning, it is sim$l! the res$onsibilit! of the organi+ation to see that it is leaned fre,uentl! enough to make it a e$table to an!one, rather than setting aside a ) lean s$a e) for staff and allowing $ubli s$a e to deteriorate. In in$atient settings, the s$a e around the nurses3 station is often a site where en"ironmental mentalism is e"ident. :re,uentl!, staff ongregates here and obser"es the beha"iors of $eo$le on the unit from a distan e. It is also a $la e where staff on"erse informall!. Indi"iduals re ei"ing treatment who a$$roa h are shooed awa! from this staff territor!. The rationali+ation is that staff must )monitor the milieu) and ensure safet! on the unit. 4et in realit! this fun tion would be better ser"ed if staff were mi*ing with $eo$le on the unit, influen ing the milieu b! engaging $eo$le and su$$orting "arious a ti"ities. The real fun tion of the nursing station is to on"e! a sense of su$eriorit! and ontrol. 6ften this im$ression is em$hasi+ed b! the

use of $le*i/glass di"iders or e"en hain/link aging. In one "er! sad $la e familiar to the authors, staff worked within a entrall! lo ated $le*i/glass en losure. This en losure was surrounded in turn b! a high ounter and lients were onl! $ermitted at the $erimeter be!ond the ounter, usuall! seated in a line of re liners fa ing inward toward the nursing station. Bn"ironmental offensi"eness is often ombined with $ro edural mi ro/aggressions to $rodu e $arti ularl! dis$araging messages toward $eo$le using ser"i es. :or e*am$le, from the $atients3 $oint of "iew, the ) all for medi ation) on an in$atient unit more resembles a attle all than a aring distribution of hel$ful medi ations. In a regular hos$ital setting, the staff indi"iduall! distributes medi ations to $atients. 6n man! $s! hiatri units, staff ha"e the $atients all line u$ at ertain times of da! to re ei"e their dail! doses. This im$ersonal $ro ess further reinfor es the de$ersonali+ation of the indi"idual and ontributes to the sense of the $erson being more a hart number, a diagnosis or an ob1e t rather than a uni,ue indi"idual human being. Innumerable e*am$les of mentalism in design e*ist in lini al settings. @! themsel"es, the! often seem like small on erns, and the $erson who seeks to address them is fre,uentl! a used of being $ett!. 4et taken together, these small, belittling messages in the $h!si al en"ironment ha"e a ma1or im$a t on $eo$le. .gain, a good general guideline in e"aluating the en"ironment is to refle t u$on how we would feel oming into the setting seeking ser"i es. Trauma and $e%traumati&ation

Mentalism an ause further diffi ulties for those who ha"e a $ast histor! of trauma. There is great negligen e in obtaining trauma histories from $eo$le re ei"ing mental health ser"i es e"en though a"ailable studies indi ate that a huge number of $eo$le, between 9GH / EGH, in the $ubli mental health s!stem are affe ted %08, 09, 0='. -ele ti"e inattention to a $ast histor! of abuse often auses lini ians to fail to diagnose the root ause of $s! hiatri disabilit!. )I was horribly abused as a child. My mother physically and emotionally abused me even prenatally by trying to 1ump off of tables at wor! #for which she was fired%. My father was see!ing divorce and custody when he died in a car accident 1ust before I turned two years old. (rom the court investigators report, my mother would have been found to be an abusive and unfit mother and my father would have been granted custody. 'e would have been the first male parent to have been awarded sole custody of minor children in the state of "hio had he lived. My mother remarried when I was seven years old. My stepfather was se-ually abusive from the time I was age seven until I moved out of the house at age seventeen. o cope with this abusive environment, I learned to dissociate in a couple of ways. I blan!ed out the memories of the abuse, I could both numb my body to feel no pain or I could actually leave my body and e-perience a sort of floating out-of-body e-perience. I did this to minimize the fear and the pain I felt. 5ears later, when these memories, that I'd successfully repressed, started to intrude, the way I coped with the painful flood, lead me to become a mental patient. A typical e-perience would have me searching for some way to cut myself to try and 3uell the overwhelming feelings of pain and fear that welled up in huge flashbac!s. (or me, cutting was a way to overcome the pain. It created another focus. It was li!e stubbing your toe in the dead of night when you get up to get something for a headache. he pain in your toe ma!es the headache become forgotten and thus go away." -).$.

Clearl!, there is a need for more resear h on $s! hiatri disabilit! among $eo$le who ha"e a histor! of trauma. In addition, there is a need for training to in rease sensiti"it! and understanding of staff regarding how to gather data on abuse histories and how to hel$ $eo$le who ha"e e*$erien ed abuse. It is im$ortant to understand that, due to the $ower differential between staff and re i$ients, man! $s! hiatri inter"entions trigger or retraumati+e the sur"i"or %0D, 0E, 0I'. "A typical response on the part of staff to these episodes :of cutting; was to strip me, place me in restraints and seclusion and to in1ect powerful drugs. I reacted very badly to these "interventions." I !ic!ed and screamed and carried on something fierce. he reason for my reaction was simple. As a child, the overwhelming, all encompassing feeling while being raped by my stepfather or beaten to a pulp by my mother was a feeling of powerlessness. )ainful powerlessness. And, as I was trying to cope with those feelings as an adult in a mental hospital, the very things they did to me 1ust pushed those buttons again and again. I was overwhelmed with feelings of powerlessness to which the staff responded by abusing their power and ma!ing me feel more powerless. A more appropriate interaction would have been verbal support, which offered some understanding of the pain and an alternative way of coping with the pain. At the very least, some compassionate understanding of the trauma I'd suffered and even perhaps a hug would have been far more soothing and healing. 'owever, that's probably not possible. After all, psychiatric settings have a paranoid feeling about touch. 7ven though psychiatry claims to be medical and in any medical setting touch is o!ay and even considered healing, psychiatry reacts with a paranoiac phobia about it. Instead, they'd rather abuse those who have been abused and are trying to heal from that abuse." -).$. Triggers and retraumati+ation an o ur in both the $h!si al and inter$ersonal en"ironments. B*am$les in lude s$read/eagle restraint

of a ra$e "i tim or disbelie"ing the histor! gi"en b! a sur"i"or of in est. @e ause $owerlessness is a ore element of trauma, an! treatment that does not su$$ort hoi e and self/determination will tend to trigger indi"iduals ha"ing a histor! of abuse. Peo$le ma! re/e*$erien e the hel$lessness, $ain, des$air, and rage that a om$anied the trauma. The! also ma! e*$erien e intense self/loathing, shame, ho$elessness, or guilt. Mentalist thought tends to label these negati"e effe ts of treatment in $e1orati"e terms that blame the sur"i"or; )He3s 1ust a ting out,) )-he3s mani$ulating,) )He3s attention/seeking.) These labels are often ommuni ated through the attitudes and language of staff, and be ome re/traumati+ing in themsel"es. It is essential that we re ogni+e the indi"idual3s beha"iors as $ost/traumati manifestations so that effe ti"e ser"i es an be $ro"ided to the sur"i"or of trauma and so that re/traumati+ation an be a"oided. 'ddressing Mentalism in (ervice Organi&ations Most lini ians enter the mental health field in res$onse to an inner on"i tion that $eo$le matter and that hel$ing ea h other is im$ortant. 4et u$on graduation, most of us are thrust into ser"i e organi+ations that ha"e been built u$on bureau rati or finan ial im$erati"es and the e*$e tation that mental health ser"i es will enfor e so ial ontrol. 6ften, lini ians find that the goal of $ro"iding ,ualit! ser"i e to indi"iduals has been su$er eded in these organi+ations b! the goals of generating $a$erwork or re"enue. In these settings, lini ians are at risk of be oming estranged from the ore "alues that gi"e their work meaning and life. .lienation from

"alues and disa$$ointment in )the s!stem) ause man! lini ians to burn out and to be ome hardened in the !ni al, mentalist beliefs that $er"ade these organi+ations. 6ften, lini ians will feel $ulled b! organi+ational or grou$ d!nami s to use $e1orati"e terms, e*$ress $essimism and ontem$t for our lients, or a t in a restri ti"e or $uniti"e manner. Ba h lini ian must take $ersonal res$onsibilit! to resist these "er! real for es in our work. Des$ite organi+ational $ressures, we an establish the lear e*$e tation for oursel"es that we will treat the $eo$le we ser"e with dignit! and res$e t, and that a"ing in to dis rimination and s a$egoating of lients is ne"er )6K.) This does not ne essaril! mean that we an $ersonall! make u$ for s!stemi defi its su h as ga$s in the ontinuum of ser"i es or inade,uate resour esA in most instan es we annot. Howe"er, no matter what the ir umstan e, we an endea"or to a$$roa h $eo$le with em$ath! and genuine on ern, and treat our lients, as we would like to be treated. 5e must also find the ourage to o$enl! onfront dis rimination when we find it. Mentalism, like ra ism or se*ism, is abuse. 5e annot underestimate the damage that is done to indi"iduals when mentalist attitudes dominate ser"i e deli"er!. "At one time, I wor!ed with a team in which two team members were clearly invested in a mentalist view of the people we served. +henever I made suggestions about client-directed ways to address our clients' needs, these team members typically responded "+e've already tried that," " hat won't wor!," "5ou're 1ust being manipulated," "'e's 1ust a sociopath," ",he can't do that," "'e's not ready," ")eople never really change," "<on't be so na=ve." "ther team members allowed these responses to go unchallenged. As a result, we consistently left these meetings feeling embittered and discouraged

about our wor!, and our team process was constantly overshadowed by this 1udgmental, angry, and punitive attitude. &ot uncommonly, I was approached after the meeting by other team members who offered support for my suggestions, but because this support never occurred within the group, I continued to be alienated and abused by the team, much as our clients often said they felt. &eedless to say, we were not effective in helping many people, and the prevailing mean-spirited attitude detracted from all our wor! as a team. <espite the fact that I had been hired into a position of leadership as team psychiatrist, I found that I was powerless to change the long-standing tradition of cynicism and mentalism in this group. My refusal to share in that negative attitude made me a traitor to the group and a new target for attac! in a parallel process that I li!ened to that observed in psychotherapy supervision." -/.6. To hange this situation the grou$ needed two things; su$$ort from leadershi$ and su$$ort from within the team. Management needed to $ro"ide su$er"ision to the team members who had ado$ted a !ni al, mentalist attitude to learl! ommuni ate that dis rimination of this sort would not be tolerated. The! needed lear feedba k about the deleterious effe t that their negati"it! had on their $erforman e as $rofessionals and guidan e to establish and im$lement a $lan for amelioration. Clear $oli ies were also needed that in luded )+ero/ toleran e) for mentalist dis rimination. #ust as em$lo!ees would ho$efull! be dismissed for dis$araging se*ual or ethni remarks, staff who are entren hed in negati"e stereot!$es, attitudes, and beliefs about the $eo$le we ser"e need to be remo"ed from ser"i e organi+ations to kee$ them from harming lients and destro!ing organi+ational morale. The team also needed in$ut from the team members who ontinued to ha"e ho$e and res$e t for our lients. Their silen e was taken within the grou$ to be ta it agreement, and the uns$oken

message was that mentalist $re1udi es were the a e$ted standard of the grou$. -im$l! to affirm ho$e and $ositi"e "alues, to ,uestion the $osition of the !ni al members, or to e*$ress agreement with an alternati"e a$$roa h would ha"e greatl! diffused the $ower of the highl! "o al, angr!, and "indi ti"e team members. This e*am$le illustrates the im$ortant role of the b!stander in the $er$etuation of mentalism. @!standers wield great $ower both when the! s$eak u$ and when the! are silent. -ilen e in the fa e of in1usti e or abuse is a subtle but "er! real form of dis rimination. It allows the abuse to ontinue and gi"es the im$ression of su$$ort. 6ften $eo$le kee$ silent be ause the! orre tl! $er ei"e that the! will be ome the ne*t ob1e t of atta k if the! inter"ene on behalf of a $erson re ei"ing ser"i es. These atta ks an admittedl! be "i ious and an in lude slander, libel, "erbal and $h!si al abuse. Howe"er, we need to onsider the im$a t of our silen e. -u$$orting dis rimination through silen e is reall! no different than $er$etrating the in1usti e. 2ltimatel!, it ommits us all to li"ing under the t!rann! of $eo$le who ha"e hosen to relin,uish their "alues and ideals. Combating dis rimination re,uires ourageous and de isi"e inter"entions that frighten most administrators. Dis rimination annot be orre ted through ) om$romise) and )gradual $hiloso$hi al hange.) 5hen we find dis rimination, it needs to be in isi"el! eradi ated. Partial solutions to dis rimination do onl! one thing / the! $er$etuate the in1usti e. 6ne annot address the ob1e tionable message of se$arate restrooms b! mo"ing )se$arate but e,ual) fa ilities loser together. The 2.-. ould not address the in1usti e of den!ing .fri an/.meri ans their right to "ote b! offering indi"iduals

)0<7 of a "ote.) 6ne annot )ease) $eo$le into using res$e tful language b! tolerating mentalist or ra ial slurs. B,ualit! means e,ualit!, res$e t means res$e t, and an!thing less is dis rimination and o$$ression. Moving from )!ower%Over) to )!ower%(haring) Bradi ating )isms) like mentalism re,uires that we hange our "iew of $ower relationshi$s. 5e must be able to en"ision an intera tion between $eo$le that is based on mutual $ersonal em$owerment and res$e t rather than one $erson being )on to$) and the other )on the bottom.) -u h a relationshi$ has been termed )$ower/sharing.) These relationshi$s a knowledge the strengths and limitations of both $arties, and build u$on ommon goals, "alues, and on erns through a $ro ess of ollaboration and negotiation %7G, 7&, 70'. In $ower/sharing lini al relationshi$s, the lini ian no longer de ides what is best for the re i$ient of the ser"i e. Instead, the indi"idual re ei"ing the ser"i e defines the goals and $lans for re o"er!. The lini ian3s role is to assist the $erson to de"elo$ the $lan and to fa ilitate its im$lementation. The $ower/sharing relationshi$ a knowledges that the lini ian cannot make real de isions for the $erson in treatment, sin e that $erson will b! ne essit! lea"e the lini at the end of the a$$ointment and make innumerable inde$endent $ersonal de isions e"er! da! that determine the out ome of her<his life. The lini ian a ts mu h like a onsultant to the re i$ient, $ro"iding information, treatment o$tions, a ess to

ommunit! resour es, su$$ort, insights, and feedba k that the $erson an draw u$on in his<her own sear h for re o"er!. . ommon mis on e$tion about the $ro ess of redu ing dis rimination based on mentalism is that amelioration means role re"ersal. It is often assumed that those who were $ower/down, on e em$owered, will assume an o$$ressi"e stan e towards $eo$le who formerl! were $ower/u$. This mis on e$tion auses man! $eo$le to retreat from addressing the issue of dis rimination. Power/sharing does not mean that lini ians must obe! the di tates of the $erson ser"ed, and does not obligate the lini ian to do an!thing unethi al or illegal. . $art of the lini al relationshi$ is o$en, res$e tful feedba k and ommuni ationA this in ludes honest dis losure about wh! a lini ian ma! feel unable to su$$ort a $arti ular ourse of a tion. 5hen onfronted with a re,uest that s<he annot su$$ort, the lini ian needs to be onstantl! "igilant for en roa hing mentalist attitudes. The lini ian ma! feel irritated or offended b! the re,uest. In these ir umstan es, it is onl! human to rea t in a 1udgmental or $uniti"e manner. :or e*am$le, when a lient re,uests a $res ri$tion for Jalium, it is ommon for lini ians to flatl! refuse and label the $erson as )drug/seeking.) In a $ower/sharing mode, the lini ian would earnestl! e*$lore the reasons for this re,uest. -<he would use this o$$ortunit! to dis uss the underl!ing reasons for the refusal, in luding on erns about the $erson3s health and the risk of addi tion, the $otential for reating more medi al $roblems for the $erson, legal on erns, alternati"e means of managing an*iet! or insomnia and so forth. 2ltimatel!, the lini ian might e*$ress genuine regret that s<he feels unable to fulfill the $erson3s re,uest. Though the $erson3s

wishes are not fulfilled, su h dis ussions generall! ommuni ate the lini ian3s genuine on ern and ons ientiousness regarding the $erson3s are. In m! e*$erien e, this "irtuall! alwa!s dee$ens the trust and res$e t within the lini al relationshi$, and sets the tone for a ollaborati"e sear h for treatment alternati"es. 5ithin the onte*t of this sort of trusting relationshi$, $eo$le e"en sometimes withdraw their re,uest in res$onse to the $ro"ider3s on erns. .t times, lini ians laim that a re i$ient is unwilling to work on treatment goals or )a ts out) in res$onse to the lini ian3s refusal to su$$ort the $erson3s $lan. In the ma1orit! of these ases, the authors ha"e found that the lini ian has set u$ the onfli t b! treating the $erson in a disres$e tful, 1udgmental, or dismissi"e manner. :or e*am$le, one ommunit! $s! hiatrist in our a ,uaintan e om$lained bitterl! about the )abusi"e beha"ior) of )borderlines) admitted to the in$atient unit. It was later learned that this man denied $eo$le3s re,uests for T!lenol for $ain, refused them an! medi ations for slee$, and told $eo$le that the! were )mani$ulati"e) for oming to the hos$ital. It is unfortunatel! ommon for lini ians to 1ustif! mentalist beha"ior b! stating that the $erson oming for ser"i es was demanding, angr!, or )needed limits.) It is im$ortant to kee$ in mind that it is alwa!s the clinician's res$onsibilit! to initiate the res$e tful tone of the lini al relationshi$ and to ulti"ate $ower/sharing in that relationshi$. 5hen res$e tful ommuni ation breaks down, the first thing the lini ian should ask her<himself is whether s<he has inad"ertentl! e*$ressed mentalist $re1udi es that ma! ha"e disru$ted the thera$euti $ro ess. If this does not seem to be the ase, then

one an onsider whether the indi"idual re ei"ing the ser"i e is ha"ing diffi ulties with inter$ersonal ommuni ation. Culti"ating res$e tful ommuni ations with $eo$le in the $resen e of onfli t ma! entail listening res$e tfull! to the $erson3s anger and frustration, des$ite its un$leasantness, and hel$ing the $erson to e*$ress these feelings asserti"el! and effe ti"el!. The *enefits of !ower%sharing There are man! benefits for the lini ian who hooses to onfront mentalism in his<her thinking. Most im$ortantl!, stri"ing for e,ualit! and res$e t in our lini al relationshi$s brings us loser to the "alues that attra ted most of us to lini al $ra ti e in the first $la e. It refo uses us on relationshi$s as the "ehi le to healing and on ser"i e to others as our most im$ortant goal. @! doing this, $ower/sharing relationshi$s restore our ore "alues and e*$ress our integrit!. Part of the $ower/sharing relationshi$ in"ol"es sin ere efforts to understand, rather than label or 1udge, the $ers$e ti"e of the $erson ser"ed. :rom that understanding, the lini ian and the $erson seeking ser"i es then ollaborate to de"ise solutions that are uni,uel! suited to the $erson3s needs. This reati"e $ro ess an refresh us and hel$ us to learn and grow $rofessionall!. Power/sharing also in reases the effi a ! of lini ians. Jer! often our energ! as lini ians is frittered awa! in efforts to get $eo$le to onform to our e*$e tations or fit into our idea of a hel$ful $rogram. 5e lose sight of the fa t that ea h indi"idual has uni,ue needs and $riorities, and that, unless the $erson feels that these are being

addressed, s<he is unlikel! to be moti"ated to $arti i$ate in the ser"i e. :or e*am$le, the staff of one $rogram s$ent an inordinate amount of energ! $ersuading and $ressuring $eo$le to attend all the grou$s at da! treatment. The! found that "oluntar! $arti i$ation was mu h better when the! hanged the $rogram to offer a wider "ariet! of o$tions that refle ted onsumer $referen es and in luded o$$ortunities for work. -taff found the! had mu h more time to work reati"el! and indi"iduall! with $eo$le when the! no longer felt the! had to be )traffi o$s.) In relationshi$s based on $ower/sharing, dilemmas and res$onsibilit! are also shared. Clini ians an relin,uish the role of ha"ing to $res ribe the right solutions for $eo$le, and an instead dis uss $ros, ons, o$tions, and re ommendations with the em$owered onsumer. The $erson re ei"ing the ser"i e is in"ol"ed dire tl! in de"elo$ing the ser"i e $lan. Bssentiall!, this a$$roa h takes informed onsent one ste$ further into the realm of informed de ision/making. In the former, the lini ian arri"es at a on lusion about the best treatment, and seeks the $erson3s $ermission to $ro eed. In the latter, the lini ian $re$ares the re i$ient to make his or her own de isions regarding treatment. The lini ian is free to share his<her on erns and misgi"ings about the ser"i es with the $erson, and to re ei"e as well as gi"e su$$ort. Informed, ollaborati"e de ision/making $rote ts both the re i$ient and the lini ian. @! full! addressing the $ossible out omes of treatment de isions, $ower/sharing redu es the risk to the $erson re ei"ing ser"i es. The well/informed onsumer an a ti"el! redu e serious onse,uen es of medi ation side effe ts through "igilan e

and earl! inter"ention. (ikewise, one an $lan $roa ti"el! for $ossible rises, redu ing risk b! $a"ing the wa! for $rom$t inter"ention in an emergen !. The lini ian is $rote ted from some of the most ommon allegations of $s! hiatri mal$ra ti e. -u h allegations often stem from $oor ommuni ation between lini ian and lient and inade,uate dis ussion of $ossible side effe ts of medi ations. Contrar! to $o$ular belief, $erfun tor! informed onsent forms do not alwa!s stand u$ to legal s rutin!. Collaborati"e ser"i e $lanning, res$e tful relationshi$s with $eo$le, and thoughtful do umentation remain the most effe ti"e $rote tions against liabilit! laims. . fo us on e,ualit!, dignit!, and res$e t in mental health ser"i es will hel$ $eo$le to heal. .ndrew Phel$s, an a ti"ist and originator of the . ountabilit! mo"ement, has alled this $ro ess the restoring of )e,uities) %77'. He belie"es that the traumas that aused $eo$le3s emotional distress, om$ounded b! the traumas and disenfran hisement the! e*$erien e as a result of mentalism, are the real sour e of $s! hiatri disabilit!. .s noted earlier, $ost/traumati effe ts of trauma an in lude ho$elessness, feelings of worthlessness, a$ath!, anger, nihilisti beliefs, withdrawal, and loss of trust. To begin to heal, the indi"idual must begin a $ro ess of o"er oming these in1uries. Howe"er, the nature of $ost/traumati effe ts makes it diffi ult to embark on this $ro ess. :or e*am$le, it is hard to in"est effort in one3s life if one feels worthless or to onne t with other $eo$le if one annot trust. Dr. Phel$s3 model suggests that ser"i es and organi+ations need, abo"e all, to hel$ $eo$le to o"er ome the effe ts of trauma. To do this, the! must e*$ress ho$e and affirm the inherent "alue and

dignit! of the $erson, irres$e ti"e of his<her urrent diffi ulties. The! need to on"e! res$e t and su$$ort the $erson3s abilit! to dire t the ourse of her<his own life. The! need to model a e$tan e and em$athi understanding of differen es between indi"iduals. The! also must $reser"e a ountabilit! for the ,ualit! and im$a t of inter$ersonal intera tions within the organi+ation. Dr. Phel$s belie"es that this a$$roa h is most likel! to o"er ome indi"idual, s!stemi , and so ietal barriers to re o"er!. 5hen organi+ations or ser"i es fail in these goals, the! tend to reinfor e $ost/traumati effe ts. :or e*am$le, $e1orati"e labels su$$ort feelings of worthlessness, mentalist $rognosti ation erodes ho$e, and unilateral treatment $lanning undermines trust. -u h e*$erien es tend to be re/traumati+ing for $eo$le who are attem$ting to address re o"er! and onl! worsen their distress. (ummary +lini ians are not immune from the $er"asi"e effe ts of $re1udi e against $eo$le who ha"e re ei"ed $s! hiatri labels. 2nfortunatel!, negati"e stereot!$es and assum$tions are often interwo"en with lini al $ra ti e, language, $ro edure, and e"en the $h!si al en"ironment. Cenerall!, we are unaware of our $re1udi es and of the in1ur! we ause the $eo$le we ser"e through our mentalist beliefs, and lini ians often gi"e "arious 1ustifi ations for the wa! things are traditionall! done. . good rule of thumb to e"aluate for the $resen e of dis rimination is to refle t on what our own res$onse would be if we were to re ei"e the same treatment.

It is im$ortant that we onfront dis rimination when we find it, in oursel"es and in others. .s $ainful as it ma! be to onsider our role as $er$etrators of mentalism, lini ians must ome to gri$s with both our $ersonal mistakes and our $arti i$ation in a $rofession that histori all! has done mu h to abuse the $eo$le who ame for are. In truth, we need to undergo our own $ro ess of healing and re o"er! in order to unlearn 1udgmental beha"iors, ontrolling attitudes, and negati"isti belief s!stems. In an ideal world, lini ians would be able to offer unlimited resour es to their lients in organi+ations in whi h ser"i e was the first $riorit!. In realit!, resour es are generall! insuffi ient to $eo$le3s needs and ser"i e takes a ba k seat to fis al and administrati"e on erns. Des$ite these real and serious barriers, ea h lini ian has a $rofessional res$onsibilit! to be a ountable for the ,ualit! of her<his intera tions with $eo$le seeking ser"i es. Ba h of us an hoose to ommuni ate ho$e, on ern, and res$e t. 5e an be de$endable and trustworth!. 5e an take res$onsibilit! for ,uestioning our assum$tions, admitting the limits of our knowledge, and broadening our skills. . lient/dire ted, egalitarian a$$roa h to ser"i es will ha"e man! benefits in luding im$ro"ed effi a !, redu ed risks, greater reati"it!, and greater satisfa tion for both lini ian and onsumer. In doing all these things, we will im$ro"e the ,ualit! of our li"es as well as those of the $eo$le we ser"e. &. Chamberlin # "n "ur "wn> )atient-/ontrolled Alternatives to the Mental 'ealth ,ystem >ew 4ork; M Craw/Hill, &IDE. 0. Pier e C K6ffensi"e Me hanismsL in he 2lac! ,eventies, :.@arbour, ed., %@oston;Porter -argent, &IDG', 0=9/0E0.

7. Deegan P ,pirit 2rea!ing> +hen the 'elping )rofessions 'urt The Humanisti Ps! hologist &IIGb, &E%7';7G&/7&7. 8. Ridgewa! P he ?oice of /onsumer in Mental 'ealth ,ystems> A /all (or /hange @urlington; Center for Communit! Change Through Housing and -u$$ort, Trinit! College of Jermont, &IEE. 9. @laska @ ):irst Person . ount; 5hat It Is (ike to @e Treated (ike a CMI) ,chizophrenia 2ulletin &II&, &D%&';&D7/=. =. (o"e1o! M )B*$e tations and the Re o"er! Pro ess) ,chizophrenia 2ulletin &IE0, E%8';=G9/=GI. D. Deegan P )Re o"ering 6ur -ense of Jalue .fter @eing (abeled) @ournal of )sychosocial &ursing &II7, 7&%8';D/&&. E. Deegan P ,pirit 2rea!ing> +hen the 'elping )rofessions 'urt The Humanisti Ps! hologist &IIGb, &E%7';7G&/7&7. I. 2n+iker R ) o be a mental patient" &IE8 &G. Harding CM, Mahniser # )Bm$iri al Corre tion of -e"en M!ths about - hi+o$hrenia with Im$li ations for Treatment) Acta )sychiatr ,cand &II8, IG%su$$l 7E8';&8G/&8=. &&. Harding CM, Mubin #, -trauss #- )Chroni it! in - hi+o$hrenia; :a t, $artial fa t, or artifa tF) 'ospital and /ommunity )sychiatry &IED, 7E%9';8DD/8E=. &0. Harding CM, Mubin #, -trauss #- )Chroni it! in - hi+o$hrenia Re"isited) 2ritish @ournal of )sychiatry &II0, &=& %su$$l. &E';0D/7D. &7. .nthon! 5., Rogers B, Cohen M, Da"ies R )Relationshi$s @etween Ps! hiatri -!m$tomatolog!, 5ork -kills, and :uture Jo ational Performan e) )sychiatric ,ervices .$ril &II9, 8=%8';797/ 79E. &8. .nthon! 5., #ansen M. )Predi ting the "o ational a$a it! of the hroni all! mentall! ill; Resear h and im$li ations) American )sychologist &IE8, 7I;97D/988.

&9. Cramer, #. )Com$lian e 5ith Medi ation Regimens for Mental and Ph!si al Disorders) )sychiatric ,ervices :ebruar! &IIE, 8I%0'; &I=/0G&. &=. Pa!kel B- )Ps! hothera$!, Medi ation Combinations, and Com$lian e) @ournal of /linical )sychiatry &II9, 9=%su$$l &';08/7G. &D. .,uila R, 5eiden P#, Bmanuel M )Com$lian e and the Rehabilitation .llian e) @ournal of /linical )sychiatry &III, =G%su$$l &I';07/0I. &E. :rank B, Ku$fer D, -iegel ( ).llian e >ot Com$lian e; . Philoso$h! of 6ut$atient Care) @ournal of /linical )sychiatry &II9, 9= %su$$l &';&&/&=. &I. )Tardi"e D!skinesia; -ummar! of a Task :or e of the .meri an Ps! hiatri .sso iation) American @ournal of )sychiatry 6 tober &IEG, &7D%&G';&&=7/&&D0. 0G. Munet+ MR, @en1amin - )How To B*amine Patients 2sing the .bnormal In"oluntar! Mo"ement - ale) 'ospital and /ommunity )sychiatry >o"ember &IEE, 7I%&&';&&D0/&&DD. 0&. (eo R# )Mo"ement Disorders .sso iated with the -erotonin -ele ti"e Reu$take Inhibitors) @ournal of /linical )sychaitry 6 tober &II=, 9D%&G';88I/898. 00. Dubo"sk! -(, Thomas M )Tardi"e D!skinesia .sso iated with :luo*etine) )sychiatric ,ervices -e$tember &II=, 8D%I';II&/II7. 07. .hmed -, Chenga$$a K>R, >aidu JR, @aker R5, Pare$all! H, - hooler >R )Clo+a$ine 5ithdrawal/Bmergent D!stonias and D!skinesias; . Case -eries) @ournal of /linical )sychiatry -e$tember &IIE, 9I%I';8D0/8DD. 08. Craine (-, Henson CB, Colli"er #., et al )Pre"alen e of a histor! of se*ual abuse among female $s! hiatri $atients in a state hos$ital s!stem) 'ospital and /ommunity )sychiatry &IEE,7I;7GG/7G8. 09. @r!er #@, >elson @., Miller #@, et al )Childhood se*ual and $h!si al abuse as fa tors in adult $s! hiatri illness) American @ournal of )sychiatry &IED, &88;&80=/&87G.

0=. #a obson ., Ri hardson @ ).ssault e*$erien es of &GG $s! hiatri in$atients; B"iden e of the need for routine in,uir!) American @ournal of )sychiatry &IED, &88;IGE/I&7. 0D. Doob D K:emale se*ual abuse sur"i"ors as $atients; a"oiding retraumati+ationL .r hi"es of Ps! hiatri >ursing, .ugust &II0, =%8';089/09&. 0E. Harris M KModifi ations in ser"i e deli"er! and lini al treatment for women diagnosed with se"ere mental illness who are also the sur"i"ors of se*ual abuse traumaL #ournal of Mental Health .dministration, :all &II8, 0&%8';7ID/8G=. 0I. #ennings . K6n being in"isible in the mental health s!stemL #ournal of Mental Health .dministration, :all &II8, 0&%8';7D8/7ED. 7G. Deegan P ,pirit 2rea!ing> +hen the 'elping )rofessions 'urt The Humanisti Ps! hologist &IIGb, &E%7';7G&/7&7. 7&. Kisthardt 5B, K. strengths model of ase management; the $rin i$les and fun tions of a hel$ing $artnershi$ with $ersons with $ersistent mental illnessL in he ,trengths )erspective in ,ocial +or! )ractice, Dennis -aleebe!, ed., %>ew 4ork; (ongman Publishing Crou$, &II0', 9I/E7. 70. (a+are ., Bisenthal -, 5asserman ( )The Customer .$$roa h to Patienthood) Archives of Aeneral )sychiatry Ma! &ID9, 70;997/99E. 77. Personal ommuni ation.