how mentalism in the mental health system harms people
Post on 01-Jan-2017
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1
Overcoming Mentalism
The trip from mental patient topsychiatric survivor
2
3
Mentalism
Discrimination against peoplewho are receiving or who havereceived psychiatric treatment.
4
Other common "isms"
RacismSexismAgeism
5
Common Mentalism
Multiple small insults andindignities that the labeledperson suffers every day
6
Dr. Chester Pierce, an African-American psychiatrist and authorwriting about racism, termed thesesmall attacks "micro-aggressions"
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Micro-aggressions
1. Not powerful individually2. hundreds, even thousands daily3. cumulates over years
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Examples of micro-aggressions(mentalism)
Derogatory Language:
He's a basket caseYou're nutsWhat a loony tuneShe's crazy
Stereotypes of people who receive mental health
services range from hostility ("They need to belocked up.") to sensationalistic media storiesdepicting people as crazed killers and "dangerous
mental patients".
9
Effects of MentalistMicro-aggressions
• Negative attitudes become internalized
• People feel ashamed• People blame themselves for their
difficulties• People feel worthless
• People feel hopeless about their future• People lose confidence about their abilities
• People feel they must hide their histories
• People fear losing their job, their friends,their credibility
• People become demoralized• People direct their anger and helplessness
back upon themselves creating aworsening spiral downward
10
Mental health professionalsrarely, if ever, acknowledgethe power of mentalism.
More often, the person who
is demoralized by his or hertreatment as a "mentalpatient" is more likely to berediagnosed, labeled"treatment resistant," oroffered more medication.
11
Mentalism, like all the "isms,"separates people into a power-upgroup and a power-down group.
In the case of mentalism, the power-up group is assumed to be "normal,"healthy, reliable, and capable.
The power-down group, composed ofpeople who have received psychiatrictreatment, is assumed to be sick,disabled, crazy, unpredictable, andviolent.
This black-and-white style ofthinking is referred to inpsychodynamic literature as"splitting."
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SS pp ll i t ti t t ii nn gg paves the way toestablish a lower standard ofservice to the power-downgroup.
13
Different Standards
An apartment that is too run down for "us" is good enough
for "them."Side effects that "we" would never tolerate should not
interfere with "their" compliance.
Medication risks that "we" find unacceptable arereasonable for "them."
"We" need credit cards to extend our salaries, but "they"need to budget "their" social security income to thepenny.
'We' "force" 'them' to take medications that cause tardivedyskinesia because 'they' are sick and 'we' are not.
If "we" were jumped upon by a group of people, takendown and forcibly injected with powerful medications,then locked up and tied down in isolation, it would be
considered assault and battery, kidnapping, andtorture. If "we" do this to "them" in a hospital, it is"treatment" for "their" own good.
If a psychiatrist threw abusive tantrums at nursing staff,s/he would be seen as "authoritarian" and "running a
tight ship" while people receiving care on the sameunit would be forcibly medicated and secluded for thesame "inappropriate" behavior.
14
Rather than acknowledge
that splitting is a
distortion of reality,
mentalist thinking leads
clinicians to establish a
category that is "almost
us":
"high-functioning."
15
High-functioning vs Low-functioning
The "high-functioning patient" is generally a person
who is just like "us" in every way except one - his or
her psychiatric label.
The power-up group can feel gratified that they have
recognized the person's contributions byacknowledging that the person isn't "just one of
them," yet the person retains his/her cautionary label
and all the negative stereotypes that go with it.
Other individuals are given the designation "low-
functioning" which clearly conveys the perception
that the person does not make valuable contributionsand is considered to be of lower worth to the
community.
At times the "low functioning" label can be usedpunitively to describe a consumer who challenges the
power of the staff
16
Labeling someone as either
or
has no healing impact upon the person in
distress and in fact, can have quite the
opposite effect. It can cause them to feel
more hopeless and helpless and thus
iatrogenically more distressed than before
being labeled in this pejorative way.
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A Simple rule of
thumb to identify
mentalist splitting
"No, but…
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Examples of Mentalist Splitting
Would I live in a certain place?
No, but…
Would I take a certain medication?
No, but…
Would I put up with a risk or side effect?
No, but…
Would I go to a certain group?
No, but…
Would I want to be talked about in a given manner?
No, but…
19
Mentalist splitting precludesgenuine empathy
Seemingly empathic statementssuch as "If I were in hisshoes…" often cover up theunderlying mentalistassumption that results fromsplitting: "But of course, Inever will be."
20
Pseudo-empathy as mentalist splitting
The implication is that the competent provider would exert
better judgment in the recipient's situation and wouldtherefore escape the difficulties facing the recipient.
The provider's imagined experiences are given more
credibility than the consumer's actual experiences.
Seemingly empathic statements become a validation of thesuperiority of the provider and can then be used to justify
inequities of power and the oppressive practices that result.
An example of this is the provider who asserts, "If I were
homeless and mentally ill, I would want to be medicatedinvoluntarily." as a justification for outpatient commitment
for others.
This provider clearly sees homelessness and psychiatric
disability as unlikely to occur in his life and s/he has,therefore, not seriously considered the complex social and
personal barriers that s/he might face in that situation.
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Providers should listen topeople and provide servicesbased upon people'sexpressed interests insteadof judging them and actingin what providers (perhapsfalsely) believe to bepeople's best interests.
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Providers should neverrefer people to anyservice or resource thatthey would not usethemselves, or subjectanyone to treatment thatthey would not welcomefor themselves.
24
This is a lofty goal in asociety that continues toprovide inadequate publicsupports and resources forpeople's basic needs.Undoubtedly mostclinicians will sometimesfind themselves in theposition of making less-than-optimal referrals.
25
Even in the face of thesedifficulties, providers cancommunicate concern forthe comfort andpreferences of the personthey are serving, andaffirm the person'sdeservedness of a betterlife.
26
It is very importantthat providers notconvey the impressionthat people must acceptsubstandard treatment,or should be gratefulfor whatever they aregiven.
27
Providers need to expresshope that the person willachieve the quality of lifethat s/he desires and offerassistance to help theperson to improve his orher circumstances.
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Providers (andeveryone else)need toencouragepeople to hopeand dream.
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A primary task ofproviders is to helppeople to find withinthemselves both theability to dream andthe belief that thosedreams can becomepossible.
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It is important tocommunicate caring andrespect by retaining a visionof people's strengths andvalue even during the badtimes, and encouragingthem always to draw upontheir better qualities andabilities.
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Clinicians tend to
believe they know a
lot more than they
actually do.
34
Most of what clinicians think
they know is actually belief in a
model or an approximation, and
very often these models prove to
be false.
35
To overcome mentalism, providers mustdevelop a deep appreciation for howmuch they don't know.
36
If providers are honest,they must admit…
They don't know why people haveexperiences that are labeled"psychiatric"
They don't know whether theseexperiences are actually illnesses
They don't know how medications affectpeople
They don't know how neurochemistryrelates to human feeling and behavior
They don't know how people recover andheal
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Mentalist thinking cancause providers to losesight of how much theydon't know.
38
Mentalist thinking can cause
providers to believe that they
have sound scientific answers for
people's problems and that the
treatment they recommend is
"right."
39
Failure of providers to recognize thelimits of their knowledge can lead them toact prematurely and restrictively. Theytend to when theyshould , and
when theyshould .
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Mentalism in
treatment
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Typically, when treatments are ineffective orunacceptable, the recipient is blamed. He orshe is "treatment-resistant," uncooperative,""non-compliant," or "characterologic" andhas therefore failed the provider rather thanthe other way around.
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S/he may even be pressured, threatened, or coerced toaccept the treatment, despite the fact that it hasalready proven to be inadequate. This is particularlycommon in the case of the person who refuses apsychotropic medication due to side effects; cliniciansoften insist upon "compliance" despite the person'sexperience of physical discomfort, neurologicalimpairment, or other evidence that the treatment isnot effective.
S/he may even be pressured, threatened, or coerced toaccept the treatment, despite the fact that it hasalready proven to be inadequate. This is particularlycommon in the case of the person who refuses apsychotropic medication due to side effects; cliniciansoften insist upon "compliance" despite the person'sexperience of physical discomfort, neurologicalimpairment, or other evidence that the treatment isnot effective.
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To combat this mentalist prejudice,providers need to modify theirassumptions and approach people in amanner that acknowledges theimperfections of the provider's tools. Therecipient's lack of response or objectionsto the treatment must be assumed to bereasonable and credible.
44
When treatment fails,
it is always due to the
short-comings of the
treatment.
45
short-comings of treatmentmay include:
• inadequate understanding of the person or
his/her problems
• medication side effects
• poor match between the treatment and the
person's lifestyle
• stigma associated with the treatment
• difficulty with access
• cultural unacceptability
• many other issues
46
It is the
responsibility to
initiate the response
to treatment failure
47
Mentalism in Language
(mental health jargon)
48
Obvious terms:
basket case
loony tune
nuts
fruit cake
etc.
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The offensive aspects of seemingly
professional terminology are often
more subtle. How these terms areused is generally more important than
their overt meaning. Interestingly,
mental health professionals oftenobject that they "need" these words to
communicate psychiatric concepts.
Yet most of the offensive terminologyis non-medical and non-specific, and
could easily be expressed in a more
accurate, less offensive manner.
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Example:
Decompensate is used colloquially to
indicate that a person is having more
distress. It does not refer to a specific
clinical finding, spectrum of symptoms, or
event. The clinician who is referred a
person who has "decompensated" knows
nothing about the person's needs or history.
Interpersonally, the term is generally used to
designate someone who is defective and
fragile, who cannot take care of him- or
herself, and who cannot tolerate stress and
therefore falls apart.
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"Decompensating"is an us-them term
52
Under stress "we" may not do well; "we"
may cocoon, take to bed, get bummed out,
get burned out, get a short fuse, throw
plates, scream, call in sick, or need a leave
of absence.
"They" decompensate.
53
An example of a better way to
describe a situation than using theterm decompensate:
"After the break-up with hergirlfriend, Mary couldn't sleep. Shestarted pacing at night and
complained of hearing voices."
This brief statement factuallydescribes Mary's experience and givesmeaningful information that begins tosuggest interventions that may behelpful.
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The demotion from "us" to"them" is a loss of one'sdesignation as a person.
The demotion from "us" to
"them" is a loss of one's
designation as a person.
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A person with a diagnosis canbecome, "a schizophrenic" or "abipolar" or "a borderline," etc.
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People who have internalizedthe dehumanizing labelingprocess will even at timesintroduce themselves as "amental patient" or "a CMI"("chronically mentally ill")rather than introducingthemselves by name.
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Professionals who are entrenched in
mentalist terminology will often
counter that this is no different thanreferring to a person as "a diabetic."
However, it is important to factor in
the reality that medical illnesses arenot associated with the negative
assumptions and prejudices that are
inferred from a psychiatric label. A"diabetic" is not assumed to be
violent, unpredictable, or
incompetent.
58
In psychiatric treatment, theterm "patient" has come to be
associated withdiscrimination, coercion, and
oppression. Unlike thepatients of a dentist,
optometrist, or gynecologist,the psychiatric "patient" is
often forced to havetreatment, incarcerated
against his or her will, andstigmatized for life.
59
Much like the person who justifies the use of
ethnic slurs because s/he intends no harm,
medical personnel have continued to justify
the use of the term "patient" because theysee it as simply technical. Others defend its
use because it represents a sacred trust
between doctor and patient. These
seemingly reasonable and noble
explanations are a smoke screen for the
mentalist power dynamic: professionals are
generally accustomed to being in charge
and, as one professional once said, he's "not
about to be dictated to by a bunch of
patients." Consistent with the power
dynamic, the power-up group is comfortablewith the existing terminology and that
comfort takes precedence over the feelings,
wellbeing, and dignity of those who are
power-down.
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In activist circles, the term applied to
a person who has received psychiatric
treatment has become a very personal
choice that reflects the individual'sexperiences, feelings, and identity.
Individuals may choose to refer to
themselves as ex-patients, survivors,
consumers, or clients, or they mayrefuse a designation altogether. Civil
rights-oriented groups often refer to
"C/S/X" ("consumers/survivors/ex-patients,") while the designation
"client" remains the most common
and generally accepted term in public
mental health systems.
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Most of the time, professionals
use offensive language
unintentionally, but this makes it
no less wounding.
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To escape from mentalist attitudes and
language clinicians need to examine the
underlying meanings and functions of their
communications.
For example, if they describe someone as "a
borderline with intense dependency," "a
non-compliant schizophrenic," "an
oppositional patient," "a typical drug-
seeking antisocial personality disorder," or"a manipulative, gamey manic," are they
seeking to understand, respect, and help, or
merely pass judgment, feel superior, and
assert their professional dominance?
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It could be illuminating to ask clinicians whythey continue to use terms that offend andstigmatize the people they aspire to help.
If they lack the empathy that would motivatethem to change their language to avoid hurtingthe people they serve, what does that sayabout their integrity as healers?
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Respectful clinicallanguage shouldfocus both theclinician and therecipient on thesearch for the mostsuccessful tools forhealth and recovery.
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If a diagnosis helps aperson to understandher/his experiences andgain control over her/hislife, it is a useful tool. If itstigmatizes, communicatescontempt, and excludes theperson from services, it is aweapon of discrimination.
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More on
language
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A few quotesfrom
psychiatricsurvivors
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"I hate the word "treatment." It'sbeen twisted by the system and pervertedbeyond recognition. If they lock you upagainst your will, strip you literally andfiguratively (of your rights) and forceyou into bondage and solitaryconfinement and then inject you withpowerful and painful drugs, they call it"treatment." In every other possiblerealm on earth, this is torture and not"treatment." If they set a fifteenminute appointment for you to renewyour drugs every two weeks or month,they call that "treatment" and they canbill your insurance for payment. Iconsider it fraud."
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"To be a mental patient isto participate in stupidgroups that call themselvestherapy -- music isn't music,it's therapy; volleyball isn't asport, it's therapy; sewing istherapy; washing dishes istherapy. Even the air thatwe breathe is therapy --called milieu. "
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"Normal behaviors areNOT symptoms. Normalpeople can have a bad day,an "off" week and even a"down" month. However, ifwe exhibit those normalbehaviors on the job, we getlabeled and we are asked ifwe took our medications orif someone needs to call ourshrink."
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"There is no such thing as a'side-effect.' There are only 'effects'from taking drugs. Some effects aredesired and others are undesirable.Calling something a "side-effect"obscures and minimizes the resultantpain, suffering and misery that canbe caused by psychoactive drugs andin doing so, it discounts ourexperiences and perceptions andthus sets us up as less than we are. Itdenies our reality."
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To combat mentalism in language,clinicians should ask themselves…
• Would they use the same language if they
were speaking directly to the person?
• Would they feel comfortable having theperson read what they have written in the
person's chart?
• Would they want to be talked about in this
manner?
• Would they talk about their friends and
colleagues in this manner?
• Does this language help the person and me
to find solutions to problems and create
positive change?
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Any "No" answers, no
matter how seemingly
justifiable, indicate
that mentalism is
operating.
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Mentalismin
Prognosis
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Mentalistassumptions havecaused manyclinicians to have arather pessimisticview of the capacityfor their clients torecover.
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When one points out thelarge number of people,including many mentalhealth activists, who haveovercome their disabilities,many clinicians commonlyrespond that theseindividuals must have been"misdiagnosed" or "do notreally have schizophrenia."
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FACT
Many long-term researchstudies have shown that asignificant number ofpeople having seriouspsychiatric concernsrecover completely,irrespective of theirdiagnosis.
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No matter thedebate on theresearch, the humanimpact of mentalismin prognosis isundeniable.
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People receiving thepronouncements,
"You will have this disability forlife," or
"You will always have to takemedications," or
"You will not become alawyer/doctor/economist/teacher,"etc.
are almost invariably devastated
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FACT
The accuracy of suchpredictions is abysmal, andrepeatedly, studies haveconfirmed that the criteriathat clinicians employ tomake such predictions are notrelated to recovery.
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FACT
The APA (AmericanPsychiatric Association) hasrepeatedly stated thatpsychiatrists are unable topredict dangerousness withany degree of certainty.
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Overcoming mentalism inprognosis requires thatprofessionals critically examinetheir assumptions aboutrecovery from psychiatricdisabilities.
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In many instances,clinicians' views have beenskewed by the fact that theyare most likely to see peopleonly during the times whenthey are experiencingdistress. Those whorecover rarely come back tothe clinic or the hospital.
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Clinicians must disclose to people that they don'tknow who will recover, when, or how. In many waysthis allows clinicians to impart a very hopeful messageto everyone they serve:
No matter how painful a person's disability, no matter
how incapacitated s/he may have been, no matter howlong s/he has struggled, there is always a significant
chance that s/he will improve considerably or even
recover completely.
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Mentalismand
PsychotropicMedications
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The attitudes andpractices thatsurround the use of
psychotropicmedications areunfortunately full ofmanifestations of
mentalism.
The attitudes andpractices thatsurround the use of
psychotropicmedications areunfortunately full ofmanifestations of
mentalism.
87
In its most obvious form, theperson receiving treatment ispresumed to be "crazy" andtherefore unable to makemedical decisions, so thatmedical personnel fail toobserve the usual procedureswith respect to informedchoice.
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Often a person's objections tomedications are dismissed onthe grounds that "mentalpatients cannot appreciate thegravity of their illnesses" andtherefore the person'sexperience of the treatment isdeemed invalid.
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The myth ofcompliance is aparticularly
destructivemanifestation ofmentalism in
psychiatry.
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Nowhere in medicine arephysicians morepreoccupied with enforcing"compliance." Most non-psychiatric physicians havecome to accept thatcompliance itself is a myth.
91
Studies of "compliance"with everything fromdiabetic diets to anti-hypertensive agents showthat humans don't complywith anything. At least onethird of people in thesestudies fail to follow theirdoctors' instructions andmany studies have shownrates of "non-compliance"of over 50%.
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Yet psychiatry hascontinued to supportmeasures that focus onforcing people to complywith treatments that theyfeel are unhelpful.
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This reflects a key element in thediscrimination and mistreatment of peoplehaving psychiatric concerns:
Because mentalist prejudices portray peoplehaving psychiatric concerns as violent and
unpredictable, treatment has largely become
synonymous with social control.
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Mental health clinicianstend to equate subduinga person with treatment.
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A quiet client whocauses no communitydisturbance is deemed"improved" no matterhow miserable orincapacitated thatperson may feel as aresult of the treatment.
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As in other forms of socialcontrol, incarceration isused to contain the personwho will not comply but,because the incarcerationoccurs in a hospital, it isdeemed to be "treatment."
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When applied to otherforms of medical treatmentthis model sounds absurd.Imagine jailing a diabeticfor having dessert orincarcerating a personhaving chronic bronchitisfor lighting up a cigaretteor forgetting his/herinhaler.
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No one would find such a solutionto public health problemsacceptable because it violatespeople's right to choose theirlifestyles and medical treatment. Invirtually all other medical concerns,individuals' rights in this regardhave been upheld, irrespective ofthe possible risks to self or others.The only exception has been in thereporting and treatment of highlycommunicable diseases.
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Numerous legislative initiativesthroughout the US are presentlyproposing that people havingpsychiatric conditions be locked upin psychiatric facilities if they fail tocomply with treatment and aredeemed to be at risk of becoming ill.This clearly compromises the rightsof people having a psychiatricdiagnosis in ways that we wouldnever consider for people havingmedical diagnoses.
100
Mentalism in psychiatricpractice is also apparent inthe lack of thoroughness ininformed consent and in themonitoring of medicationside effects.
101
Informed consent is oftenobtained by merely havingpeople sign a paper onwhich possible medicationside effects are listed. Nodistinction is made betweendangerous side effects anduncomfortable ones; nosuggestions are given foridentification andmanagement of theseeffects.
102
Often, medically seriousside effects are "dumbeddown" so that people do notget an accurate view of therisks involved. Forexample, tardivedyskinesia, a potentiallypermanent neurologicalcondition caused byantipsychotic medications,is often described as"having muscle tics."
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Many people areapproached for consentonly during crises or acutebouts of their conditions,and the information isnever revisited when theperson is more able toconcentrate and processinformation.
104
The indifferent quality ofthis approach to informedconsent is clearly driven bythe mentalist powerdynamic, which acts toprotect the clinician fromallegations of negligencewithout truly informing theperson getting treatment.
105
Monitoring of sideeffects is conspicuouslyaffected by mentalistprejudices.
106
Many psychiatristsfail to examinepeople for tardivedyskinesia (TD).
107
When TD is detected early,it is often completelyreversible. If it is notdetected early, TD is oftenprogressive and permanent,so that even if themedication is stopped, theperson may continue tohave odd movements thats/he cannot control.
108
WW hh ii ll e te thh ee p pee r sr s oo nn ii sst at a kk ii nn gg tt hh eeaa nn t it i p sp s yy cc hh oo t it i ccmm ee dd ii cc aa t i ot i o n ,n , tt hh eem o vm o v ee mm ee nn tt s of Ts of TD D a ra r ee
o fo f tt ee nn mm aa ss kk ee dd .. They
also may not be apparentuntil the person isdistracted or excited.
109
The American PsychiatricAssociation recommended in 1980that psychiatrists reduce the dose ofantipsychotics on a regular basisand examine people taking thesemedications for TD annually usinga standardized assessment such asthe AIMS (Abnormal InvoluntaryMovement Scale) or DISCUS(Dyskinesia Identification SystemCondensed User Scale).
110
What typically happens in mental health
clinics:
1. Generally, individuals takingneuroleptics are encouraged to stay on amaintenance dose of medications.
2. Regular dose reductions are rare, asclinicians fear the person will"decompensate."
3. Psychiatrists typically observe theperson informally for obvious
involuntary movements and indicate inthe chart "no TD."
4. Rarely is an AIMS or DISCUSperformed or documented.
5. Generally the discussion of TD is
limited to the warning of possible"muscle tics" given in the informedconsent.
111
The net result is that yearafter year, thousands ofpeople receive antipsychoticmedications without everbeing thoroughly evaluatedfor a potentially disablingmedication side effect.
112
Why are psychiatrists failing toperform routine monitoring ofmedication risks?
• not due to time constraints, since
the modified AIMS or the DISCUStakes only 10 minutes to performand rate.
• not due to fears that people willabandon treatment, since research
suggests that ww ee ll l-il-i nfnf oo rmedrmedrecrec ii pp ieie ntnt ss tt end tend too bb ee mm oo rr eeii nn vv oo lvlv eded i inn thethe ii rr cc aa re anre andd ll ee sssslili keke lyly tt o be "no be "noo n-cn-c oo mpmp lialia ntnt .. ""
113
It is likely thatmentalism is operatinghere as elsewhere,causing psychiatrists tofeel that unidentifiedTD is somehow anacceptable risk forpeople havingpsychiatric disabilities.
114
The comparison with medical
maltreatment based upon racism,such as the Tuskegee experiment inwhich African-American men wereallowed to be exposed to the risksassociated with untreated syphilis,is inescapable.
115
Mentalism has leadto a prevalent beliefthat newerantipsychoticmedications do notcause TD.
116
Many cliniciansappear oblivious tothe fact that allantipsychoticmedications havebeen found to beassociated with thedevelopment of TD.
117
Studies showingreduced risk withnewer psycho-pharmacologicagents have beenconducted forrelatively briefperiods of time.
118
Even clozapine, the "goldstandard" amongantipsychotics, and theserotonin reuptakeinhibitor antidepressants(SSRI's) have beenassociated in rare instanceswith TD.
119
Suggestionsfor elimination
of mentalistdiscrimination
in medicationpractices:
120
1. The use of psychotropic medications toenforce social control must be separated,conceptually and in practice, from truetreatment. Psychiatrists are presentlyburdened with the unrealistic societalexpectation that they can ensure publicsafety through the use of psychotropicdrugs to control people who are labeled aspotentially deviant. Until they arerelieved of this oppressive myth, clinicalpractice will continue to reflect thepublic's mentalist prejudices rather thanthe needs of the people they serve.
121
2. Informed consent must berefined so that people receivecomprehensive and easilyunderstandable information abouttheir choices that neithercatastrophizes nor downplays thehealth risks of the treatment. Thisinformation should be reviewedwith the person periodically andneeds to go with the person ratherthan sitting in the chart.
122
3. When making treatmentdecisions, clinicians must givehighest priority to the individual'sassessment of the treatment,especially his or her subjectivereport of side effects and the impactof the medications on his/her life.Clinicians need to be aware of thebiases of others who may reportthat a person is "improved" whenin fact the person is simply toosedated or too neurologicallyimpaired by the medication to
"cause trouble."
123
4. Clinicians must abandonthe myth of compliance andfocus instead onunderstanding the decision-making processes thatpeople go through as theychoose their treatment.
124
5. Clinicians must diligently applythemselves to the task of earlyidentification of the medicalconsequences of psychotropicmedications. This should includeregular examinations for TD,appropriate blood tests for liver orkidney damage, annualophthalmology exams for peopletaking phenothiazineantipsychotics, audiology screeningfor people taking valproic acidpreparations, and so forth.
125
Mentalismand thePhysicalEnvironment
126
Power expressed inenvironmental termsincludes:
• space• privacy• safety• cleanliness• comfort• choice• access• aesthetics
127
EXAMPLE:
The person at the top of anorganization has a large privateoffice with comfortable, or evenlavish, furnishings and usuallyher/his own computer and printer.
The people at the bottom work insmall "cubes," have utilitarianfurnishings, and share facilitiessuch as refrigerator, printer,computer, and restroom.
128
Mentalismmakes thesepowerdifferenceseven morepronounced.
129
Individuals living in supportedenvironments often:
• share rooms with roommates not of their
choosing
• rarely have privacy
• use furniture that is chosen by others foreasy maintenance and durability rather than
comfort or aesthetics
• have insufficient space to display or storepersonal possessions
• have no way to lock their possessions, their
rooms, or the bathroom to insure safety and
privacy and deter theft• are given only housing options that are
run-down or located remotely
• are left to use public transportation that isinconvenient, uncomfortable, or even unsafe
130
Many of these conditionsare shared by anyone whohas little money. However,mentalism does contributeto many specificenvironmental micro-aggressions as well.
131
A common mentalistmicro-aggression,occurring in manyclinics, is simply theseparation of staffand client restrooms.
132
Separation of the facilitiesfor "staff" and "clients"mirrors the conditions inthe Southeastern US priorto the civil rights movementof African-Americans,where racist beliefs led tothe separation of all publicfacilities for "whites" and"non-whites".
133
The separation of facilitiesis often combined with alack of maintenance andprivacy in the restroomsused by clients. There areplaces where the stalls inthe "client" restroom haveno doors. This is justifiedas a "safety measure."
134
The mentalistjustification for thisdiscriminatorypractice by cliniciansis, "clients have adifferent standard ofhygiene than wehave."
135
Such mentalist attitudes are not onlycondescending but they also obfuscate theresponsibility of a public service toprovide a respectful physical environmentfor public use. If public use causes thefacility to need more cleaning, it is simplythe responsibility of the organization tosee that it is cleaned frequently enough tomake it acceptable to anyone, rather thansetting aside a "clean space" for staff andallowing public space to deteriorate.
136
In inpatient settings, the spacearound the nurses' station is often asite where environmentalmentalism is evident. Frequently,staff congregate here and observethe behaviors of people on the unitfrom a distance. It is also a placewhere staff converse informally.Individuals receiving treatmentwho approach are shooed awayfrom this staff territory.
137
The rationalization is that staffmust "monitor the milieu" andensure safety on the unit.
In reality this function would bebetter served if staff were mixingwith people on the unit, influencingthe milieu by engaging people andsupporting various activities.
138
The real function ofthe nursing station isto convey a sense ofsuperiority andcontrol.
139
Often the impressionof superiority andcontrol isemphasized by theuse of plexi-glassdividers or evenchain-link caging.
140
Environmentaloffensiveness is oftencombined withprocedural micro-aggressions toproduce particularlydisparaging messagestoward people usingservices.
141
EXAMPLE:
From the patients' point of view, the "callfor medication" on an inpatient unit moreresembles a cattle call than a caringdistribution of helpful medications. In aregular hospital setting, the staffindividually distribute medications topatients. On many psychiatric units, staffhave the patients all line up at certaintimes of day to receive their daily doses.
This impersonal process furtherreinforces the depersonalization of theindividual and contributes to the sense ofthe person being more a chart number, adiagnosis or an object rather than aunique individual human being.
142
Traumaand
Re-traumatization
143
Mentalism can causefurther difficultiesfor those who have apast history oftrauma.
144
There is great negligence inobtaining trauma historiesfrom people receivingmental health services eventhough available studiesindicate that a hugenumber of people, between50% - 80%, in the publicmental health system areaffected.
145
Selective inattentionto a past history ofabuse often causesclinicians to fail todiagnose the rootcause of psychiatricdisability.
146
There is a need foradditional training toincrease sensitivity andunderstanding of staffregarding how to gatherdata on abuse histories andhow to help people whohave experienced abuse.
147
It is important tounderstand that, dueto the powerdifferential betweenstaff and recipients,many psychiatricinterventions triggeror retraumatize thesurvivor.
148
One psychiatric survivor reports, as achild, the overwhelming, allencompassing feeling while beingraped by my step-father or beaten to apulp by my mother was a feeling ofpowerlessness. The controlling natureof psychiatric hospitalizationretriggered those feelings ofpowerlessness. Being secluded orrestrained or forcibly drugged notonly did NOT heal, they recreated thesame sense of abuse and trauma andexacerbated my condition andlengthened my stay.
149
Triggers andretraumatizationcan occur in both thephysical andinterpersonalenvironments.
150
For example, thespread-eaglerestraint of a rapevictim and,disbelieving thehistory given by asurvivor of incest,can both beretraumatizing.
151
Because powerlessness is acore element of trauma, anytreatment that does notsupport choice and self-determination will tend totrigger individuals having ahistory of abuse.
152
People may re-experience thehelplessness, pain,despair, and ragethat accompaniedthe trauma.
153
People may alsoexperience intenseself-loathing, shame,hopelessness, orguilt.
154
Mentalist thought tends tolabel these negative effectsof treatment in pejorativeterms that blame thesurvivor:
"He's just acting out,"
"She's manipulating,"
"He's attention-seeking."
155
These labels areoften communicatedthrough theattitudes andlanguage of staff,and become re-traumatizing inthemselves.
156
It is essential that werecognize the individual'sbehaviors as post-traumaticmanifestations so thateffective services can beprovided to the survivor oftrauma and so that re-traumatization can beavoided.
157
AddressingMentalism inServiceOrganizations
158
Most clinicians enter the mentalhealth field in response to an innerconviction that people matter and
that helping each other isimportant. Yet upon graduation,most are thrust into serviceorganizations that have been builtupon bureaucratic or financialimperatives and the expectation
that mental health services willenforce social control.
159
Often, clinicians find
that the goal of
providing quality
service to individuals
has been superceded
by the goal of
generating paperwork
or revenue.
160
Alienation from values anddisappointment in "thesystem" causes manyclinicians to burn out andto become hardened in thecynical, mentalist beliefsthat pervade theseorganizations.
161
Clinicians often feel pulledby organizational or groupdynamics to use pejorativeterms, express pessimismand contempt for theirclients, or act in arestrictive or punitivemanner.
162
Every clinician must take personalresponsibility to resist very realmentalist pressures in theworkplace. Despite organizationalpressures, clinicians can and mustestablish the clear expectation forthemselves that they will treat thepeople they serve with dignity andrespect, and that caving in todiscrimination and scape-goating ofclients is never "OK."
163
Clinicians must findthe courage toopenly confrontdiscrimination whenthey find it.
164
Mentalism, like racism orsexism, is abuse. Wecannot underestimate thedamage that is done toindividuals when mentalistattitudes dominate servicedelivery.
165
I have a friend who is a clinician who reported:
"At one time, I worked with a team in which two teammembers were clearly invested in a mentalist view of the people
we served. Whenever I made suggestions about client-directed
ways to address our clients' needs, these team members typicallyresponded "We've already tried that," "That won't work,"
"You're just being manipulated," "He's just a sociopath," "Shecan't do that," "He's not ready," "People never really change,"
"Don't be so naïve." Other team members allowed these
responses to go unchallenged. As a result, we consistently leftthese meetings feeling embittered and discouraged about our
work, and our team process was constantly overshadowed by thisjudgmental, angry, and punitive attitude. Not uncommonly, I
was approached after the meeting by other team members who
offered support for my suggestions, but because this supportnever occurred within the group, I continued to be alienated and
abused by the team, much as our clients often said they felt.Needless to say, we were not effective in helping many people,
and the prevailing mean-spirited attitude detracted from all ourwork as a team. Despite the fact that I had been hired into a
position of leadership, 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 attack in a parallel process."
166
To change this
situation the groupneeded two things:
• support fromleadership
• support fromwithin the team.
167
• Management needs to provide supervision toteam members who have adopted a cynical,
mentalist attitude to clearly communicate that
discrimination of this sort will not be tolerated.
• The team needs clear feedback about thedeleterious effect that their negativity has on their
performance as professionals and guidance to
establish and implement a plan for amelioration.
• Clear policies are needed that include "zero-tolerance" for mentalist discrimination.
• Just as employees would hopefully be dismissedfor disparaging sexual or ethnic remarks, staff
who are entrenched in negative stereotypes,attitudes, and beliefs about the people they serve
need to be removed from service organizations to
keep them from harming clients and destroyingorganizational morale.
168
• The team also needs input from teammembers who continue to have hope andrespect for their clients.
• Silence within the group is taken to betacit agreement, and the unspokenmessage is that mentalist prejudices arean acceptable standard for the group.
• Simply to affirm hope and positivevalues, to question the position of cynicalmembers, or to express agreement withan alternative approach would greatlydiffuse the power of highly vocal, angry,and vindictive team members.
169
This exampleillustrates theimportant role of thebystander in theperpetuation ofmentalism.
170
Bystanders wield great power bothwhen they speak up and when they aresilent.
Silence in the face of injustice or abuse is a
subtle but very real form of discrimination.
It allows the abuse to continue and gives the
impression of support.
Often people keep silent because they
correctly perceive that they will become the
next object of attack if they intervene on
behalf of a person receiving services.
These attacks can admittedly be vicious and
can include slander, libel, verbal and
physical abuse.
171
Consider the impactof silence
Supporting discrimination throughsilence is really no different thanperpetrating the injustice.
Ultimately, it commits us all toliving under the tyranny of peoplewho have chosen to relinquish theirvalues and ideals.
172
Combatingdiscriminationrequires courageousand decisiveinterventions thatfrighten mostadministrators.
173
Discrimination cannot
be corrected through
"compromise" and
"gradual
philosophical
change." When we
find discrimination, it
needs to be incisively
eradicated.
174
• Partial solutions to discrimination do only
one thing - they perpetuate the injustice.
• One cannot address the objectionablemessage of separate restrooms by moving"separate but equal" facilities closer together.
• The U.S. could not address the injustice of
denying African-Americans their right to voteby offering individuals "2/3 of a vote."
• One cannot "ease" people into usingrespectful language by tolerating mentalist orracial slurs.
• Equality means equality, respect meansrespect, and anything less is discriminationand oppression.
175
Eradicating "isms" like mentalismrequires that we change our view ofpower relationships.
We must be able to envision aninteraction between people that is basedon mutual personal empowerment andrespect rather than one person being "ontop" and the other "on the bottom."
Such a relationship has been termed"power-sharing."
These relationships acknowledge thestrengths and limitations of both parties,and build upon common goals, values,and concerns through a process ofcollaboration and negotiation.
176
In power-sharing clinicalrelationships, the clinicianno longer decides what isbest for the recipient of theservice.
Instead, the individualreceiving the service definesthe goals and plans forrecovery.
177
The clinician's roleis to assist theperson to developthe plan and tofacilitate itsimplementation.
178
The power-sharingrelationship acknowledges
that the clinician cannotmake real decisions for theperson in treatment, sincethat person will by necessityleave the clinic at the end ofthe appointment and makeinnumerable independentpersonal decisions everyday that determine theoutcome of her/his life.
179
The clinician acts much likea consultant to therecipient, providinginformation, treatmentoptions, access tocommunity resources,support, insights, andfeedback that the personcan draw upon in his/herown search for recovery.
180
A common misconceptionabout the process ofreducing discriminationbased on mentalism is thatamelioration means rolereversal. It is oftenassumed that those whowere power-down, onceempowered, will assume anoppressive stance towardspeople who formerly werepower-up.
181
Thismisconceptioncauses manypeople to retreatfrom addressingthe issue ofdiscrimination.
182
Power-sharing doesnot mean thatclinicians must obeythe dictates of theperson served, anddoes not obligate theclinician to doanything unethicalor illegal.
183
A part of the clinicalrelationship is open,respectful feedback andcommunication; thisincludes honest disclosureabout why a clinician mayfeel unable to support aparticular course of action.
184
When confronted with arequest that s/he cannotsupport, the clinician needsto be constantly vigilant forencroaching mentalistattitudes. The clinicianmay feel irritated oroffended by the request. Inthese circumstances, it isonly human to react in ajudgmental or punitivemanner.
185
Example:
When a client
requests a prescription
for Valium, it is
common for clinicians
to flatly refuse and
label the person as
"drug-seeking."
186
In a power-sharingmode, the clinicianwould earnestlyexplore the reasonsfor this request.
187
S/he would use this opportunity to discuss theunderlying reasons for the refusal, including:
• concerns about the person's health
• the risk of addiction
• the potential for creating more medicalproblems for the person
• legal concerns
• alternative means of managing anxiety
• alternative means of managing insomnia
Ultimately, the clinician might express
genuine regret that s/he feels unable to fulfillthe person's request.
188
Though the person's wishes are not
fulfilled, such discussions generallycommunicate the clinician's genuine
concern and conscientiousnessregarding the person's care. This
virtually always deepens the trustand respect within the clinical
relationship, and sets the tone for acollaborative search for treatment
alternatives. Within the context of
this sort of trusting relationship,people even sometimes withdraw
their request in response to theprovider's concerns.
189
At times, clinicians
claim that a recipient
is unwilling to work
on treatment goals or
"acts out" in response
to the clinician's
refusal to support the
person's plan.
190
In the majority ofthese cases theclinician has set upthe conflict bytreating the personin a disrespectful,judgmental, ordismissive manner.
191
Example:
The community psychiatrist whocomplains bitterly about the"abusive behavior" of"borderlines" admitted to theinpatient unit. However, thispsychiatrist denies people's requestsfor Tylenol for pain, refuses themany medications for sleep, and tellspeople that they are"manipulative" for coming to thehospital.
192
Unfortunately, it iscommon forclinicians to justifymentalist behaviorby stating that theperson coming forservices wasdemanding, angry,or "needed limits."
193
It is always the
clinician'sresponsibility to
initiate the respectful
tone of the clinical
relationship and to
cultivate power-
sharing in that
relationship.
194
When respectfulcommunication breaksdown, the first thing theclinician should askher/himself is whether s/hehas inadvertently expressedmentalist prejudices thatmay have disrupted thetherapeutic process.
195
Cultivating respectfulcommunications withpeople in the presence ofconflict may entail listeningrespectfully to the person'sanger and frustration,despite its unpleasantness,and helping the person toexpress these feelingsassertively and effectively.
196
The Benefits ofPower-sharing
197
There are manybenefits for theclinician whochooses to confrontmentalism in his/herthinking.
198
Striving for equalityand respect inclinical relationshipsbrings clinicianscloser to the valuesthat attracted mostclinicians to clinicalpractice in the firstplace.
199
Power-sharingrefocuses clinicianson relationships asthe vehicle to healingand on service toothers as clinicians'most important goal.
200
The focus on power-sharingin therapeutic relationshipsrestores clinicians corevalues and expresses theirintegrity.
201
Part of the power-sharing relationshipinvolves sincereefforts to understandthe perspective ofthe person servedrather than to labelor judge.
202
The clinician and theperson seeking services canthen collaborate to devisesolutions that are uniquelysuited to the person's needs.This creative process canrefresh clinicians and helpthem to learn and growprofessionally.
203
Power-sharing alsoincreases theefficacy ofclinicians.
204
Very often clinicians' energy isfrittered away in efforts to getpeople to conform to theirexpectations or fit into their idea ofa helpful program. They lose sightof the fact that each individual hasunique needs and priorities, and that,
unless the person feels that these arebeing addressed, s/he is unlikely to
be motivated to participate in the
service.
205
Example:
The staff of one program spent aninordinate amount of energypersuading and pressuring people toattend all the groups at day treatment.They found that voluntaryparticipation was much better whenthey changed the program to offer awider variety of options that reflectedconsumer preferences and includedopportunities for work. Staff foundthey had much more time to workcreatively and individually with peoplewhen they no longer felt they had to be"traffic cops."
206
In relationshipsbased on power-sharing, dilemmasand responsibilityare also shared.
207
Clinicians can relinquishthe role of having toprescribe the right solutionsfor people, and can insteaddiscuss pros, cons, options,and recommendations withthe empowered consumer.
208
The person receivingthe service isinvolved directly indeveloping theservice plan.
209
This approach takesinformed consentone step further intothe realm ofinformed decision-making.
210
In the existing style of informedconsent, the clinician arrives at aconclusion about the besttreatment, and seeks the person'spermission to proceed. In power-sharing informed consent, theclinician prepares the recipient tomake his or her own decisionsregarding treatment. The clinicianis free to share his/her concerns andmisgivings about the services withthe person, and to receive as well asgive support.
211
Informed,collaborativedecision-makingprotects both therecipient and theclinician.
212
By fully addressing the possible
outcomes of treatment decisions,power-sharing reduces the risk tothe person receiving services. Thewell-informed consumer can
actively reduce seriousconsequences of medication sideeffects through vigilance and early
intervention. Likewise, one canplan proactively for possible crises,reducing risk by paving the way for
prompt intervention in anemergency.
213
With power-sharing, the clinician is
protected from some of the mostcommon allegations of psychiatricmalpractice. Such allegations oftenstem from poor communicationbetween clinician and client andinadequate discussion of possible side
effects of medications. Contrary topopular belief, perfunctory informedconsent forms do not always stand upto legal scrutiny. Collaborative serviceplanning, respectful relationships with
people, and thoughtful documentationremain the most effective protectionsagainst liability claims.
214
A focus on equality,dignity, and respectin mental healthservices will helppeople to heal.
215
Some in the psychiatricsurvivor movement believethat the traumas thatcaused people's emotionaldistress, compounded bythe traumas anddisenfranchisement theyexperience as a result ofmentalism, are the realsource of psychiatricdisability.
216
As noted earlier, post-traumaticeffects of trauma can includehopelessness, feelings ofworthlessness, apathy, anger,nihilistic beliefs, withdrawal, andloss of trust. To begin to heal, theindividual must begin a process ofovercoming these injuries.However, the nature of post-traumatic effects makes it difficultto embark on this process. Forexample, it is hard to invest effortin one's life if one feels worthless orto connect with other people if onecannot trust.
217
This model suggests that services and
organizations need, above all, to help people
to overcome the effects of trauma. To do this,they must:
• express hope and affirm the inherent value
and dignity of the person, irrespective of
his/her current difficulties
• convey respect and support the person'sability to direct the course of her/his own life
• they need to model acceptance and empathic
understanding of differences between
individuals
• they must preserve accountability for thequality and impact of interpersonal
interactions within the organization
218
When organizations
or services fail in
these goals, they tend
to reinforce post-
traumatic effects.
219
Pejorative labels supportfeelings of worthlessness,mentalist prognosticationerodes hope, and unilateraltreatment planningundermines trust. Suchexperiences tend to be re-traumatizing for peoplewho are attempting toaddress recovery and onlyworsen their distress.
220
Summary
221
Clinicians are notimmune from thepervasive effects ofprejudice againstpeople who havereceived psychiatriclabels.
222
Negative stereotypesand assumptions areoften interwovenwith clinicalpractice, language,procedure, and eventhe physicalenvironment.
223
Generally, practitioners areunaware of their prejudicesand of the injury they causethe people they servethrough their mentalistbeliefs, and clinicians oftengive various justificationsfor the way things aretraditionally done.
224
A good rule of thumbfor clinicians toevaluate for thepresence ofdiscrimination is toreflect on what theirown response would beif they were to receivethe same treatment.
225
It is important thatclinicians (and everyoneelse) confrontdiscrimination whenthey find it, inthemselves and inothers.
226
Clinicians must come to grips withboth their personal mistakes andtheir participation in a professionthat historically has done much toabuse the people who came for care.They need to undergo their ownprocess of healing and recovery inorder to unlearn judgmentalbehaviors, controlling attitudes, andnegativistic belief systems.
227
In an ideal world,
clinicians would be
able to offer unlimited
resources to their
clients in
organizations in
which service was the
first priority.
228
In reality, resources
are generally
insufficient to
people's needs and
service takes a back
seat to fiscal and
administrative
concerns.
229
Despite these real andserious barriers, eachclinician has a professionalresponsibility to beaccountable for the qualityof her/his interactions withpeople seeking services.
230
A client-directed,egalitarian approach toservices will have manybenefits including improvedefficacy, reduced risks,greater creativity, andgreater satisfaction for bothclinician and consumer.
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