Sanism,stigma and the belief in dangerousness

When Hester Prynne emerges from prison at the beginning of Nathaniel Hawthorne’s The Scarlet Letter, a token of shame is fastened to the breast of her dress. Fashioned in ‘fine red cloth, surrounded with an elaborate embroidery and fantastic flourishes of gold thread’, a letter ‘A’ signifies her as an adulteress (Hawthorne, 2008, p. 55).

Stigma is ‘a mark of disgrace or infamy; a sign of severe censure or condemnation’ or ‘a stain’ (Macquarie Dictionary, 2009; Oxford English Dictionary, 1991). Stigma is something placed on a person to mark them out as defective, degenerated or, relevant to the focus of the excellent review by Jorm and colleagues in this issue, as dangerous (Jorm et al., 2012).

Jorm and co-authors concisely summarise what is known about belief in the dangerousness of people living with mental illness. They find that this belief is widespread, measurable, unrelated to age or gender, increased by the media and decreased by education and familiarity with people who live with mental illness. Consistent with the existing literature on the topic, the authors characterise the belief in the dangerousness of the mentally ill as a component of stigma. While there is little doubt that belief in dangerousness contributes to stigma, we believe it is more accurate and more useful to regard the belief in dangerousness not just as a component of stigma, but also as central to prejudice against the mentally ill. In this commentary we explain the difference between stigma and prejudice and why the distinction is important.

As the definitions connote, the term ‘stigma’ applies when an actual facet of a person is used to set them apart. Hester Prynne’s badge of shame marked her out truly as an adulteress. The tragedy that engulfs her as the novel unfolds comes, not from mistaken belief, but from Puritan intolerance of Hester’s actual infidelity. Stigma is about intolerance not misunderstanding. Those who suffer its consequences, do so because some in our society are so intolerant and lacking in compassion that they cannot accept people different from themselves.

Prejudice, on the other hand, is ‘an unfavourable opinion or feeling formed beforehand without knowledge, thought, or reason’ (Macquarie Dictionary, 2009). The belief that people with mental illness are dangerous is a prejudice. It is simply incorrect and is based either on ignorance or on an inadequate consideration of the facts. It is relevant, but hardly decisive, that there is little to suggest that the class of people with mental illness is any more likely to cause harm than any other class of people. Although it is true that people with schizophrenia are more likely to be violent than those without schizophrenia, this does not justify the belief that any particular person living with this mental illness should be properly regarded as dangerous. To be dangerous, a thing must be ‘hazardous’ or ‘unsafe’ (Macquarie Dictionary, 2009).

Applied to a class of people this implies that those who make up this class exceed some meaningful threshold for the likelihood of future harm. In fact, the class of people with schizophrenia can only be considered to fall well below any reasonably considered threshold. By way of example, patients with an established diagnosis of schizophrenia commit homicide at a rate of about 1 in 10,000 per annum (Nielssen and Large, 2010). If a risk of 1 in 10,000 homicides per year was an accepted threshold for dangerousness, then the inhabitants of many nations, including the citizens of Brazil, Mexico, Russia and South Africa and the residents of Louisiana and the District of Columbia in the USA would all be classed as dangerous. More importantly class attributions, even when undoubtedly true, are only valid when applied to the class as a whole; they have little or no utility when applied to individuals.

The misapplication of false, or even true, class attributions to individuals within that class is a common basis of prejudice. Even if it were true that women were more likely to be involved in motor vehicle accidents than men (it is not), that class observation could not be validly applied to any individual ‘woman driver’. It is true that the class of people with first-episode psychosis are more likely to commit homicide than other classes of people, but that does not make any individual person with first-episode psychosis dangerous purely because they belong to that class. Young men are much more likely to commit homicide than women or older men, but it obviously makes no sense to regard any individual male youth as dangerous, purely because they are young and male.

When people make day-to-day judgements about the dangerousness of people with mental illness, they make those judgements about individual mentally ill people and those judgements are prejudiced. It is important to distinguish them from stigmatising judgements for three reasons.

First, unlike stigmatising judgements, prejudicial judgements are not necessarily the products of small, foolish minds. We all are prone to the cognitive errors of prejudice and should not be afraid or ashamed to admit this when it is revealed. Secondly, unlike stigmatising attitudes, which are often only influenced by glacially slow cultural change, prejudice can sometimes be lifted by simple measures such as public education or the personal disclosure or conduct of a well-known person. Finally, while both stigma and prejudice may lead to discrimination, discrimination through prejudice – sexism, ageism, racism, for example – is more familiar and recognisable as discrimination than discrimination arising from stigma.

Discrimination on the basis of prejudice against people living with mental illness has been termed ‘sanism’ by the American disability law theorist Michael Perlin (Perlin, 1999). It is a concept that is only now coming to be fully appreciated. Sanism is embedded in our society. It is not only found in people’s attitudes to the mentally ill, but it is written into our laws. Currently, the mental health legislation of every Australasian jurisdiction permits the coercive treatment of people with mental illness if they are deemed likely to harm other individuals, regardless of their capacity to accept or refuse treatment. The only other class of people who are subject to preventative detention on the basis of likelihood of harm to others are sex offenders and those laws are appropriately controversial (Hayes et al., 2009). The presence of these provisions within our mental health acts (Large et al., 2008) suggests our lawmakers are just as prone to prejudice about dangerousness as anyone else.

Perlin believes that our prejudicial attitudes about the mentally ill have seen sanist provisions riddle our law and social policy (Perlin and Dorfman, 2006). We believe that prejudice against the mentally ill is best understood in terms of sanism and prejudice, rather than stigma, because we already understand the pitfalls of other prejudice-based discrimination. We know that a propensity to sexism, ageism or racism lies within us all and that we must tackle these prejudices. Now we must guard against and combat sanism just as fiercely.

See Review by Jorm et al., 2012, 46(11): 1029–1045