If Language Matters, "Stigma" Should Be Retired From Mental Health Vocabulary
Language matters! The more people use the word sanism, the more normalized it becomes. That is a catalyst to resolving the mental health crisis and preventing suicide. Source: Author
For the Daily Tar Heel’s Mental Health Collaborative, I wrote an article titled, “It’s time to replace the word ‘stigma’ with ‘sanism.’” In that article, I delivered my points about how “stigma” has served as a euphemism for the discrimination survivors of severe mental illnesses have faced. And as a survivor myself, there is no word in English that grinds my gears more than “stigma.” Why? What is sanism anyway?
As shared in my Daily Tar Heel article, “Sanism is a term that refers to systemic discrimination against those perceived or diagnosed with mental disorders.”
This sentence did not appear in my own article draft, BUT it is a concise, clear definition of sanism. The “perceived” part does acknowledge the fact that not everyone gets a diagnosis for a multitude of reasons. Even without a diagnosis, that does not make their mental health conditions any less real, and they are still very much impacted by sanism.
About its etymology, the word “sanism” has its origins in the 1960s. It was coined by Dr. Morton Birnbaum, who represented a survivor of long-term hospitalization named Edward Stephens in court. Stephens had been at Creedmoor State Hospital in New York for three decades and was diagnosed with schizophrenia. At that hospital, he faced sanism and witnessed human rights violations being committed against other survivors. Stephens sought fundamental human rights, and Birnbaum was integral in speaking with, not just for, Stephens in that quest.
It sounds far-fetched to demand people retire the word “stigma,” given how ingrained that word has become in mental health discourse. It is used everywhere by institutions, mental health organizations, mental health activists, and anywhere else mental health is being discussed. While well-intended, very rarely do they bluntly call out the oppression survivors of severe mental illnesses have faced. Stigma focuses on “having conversations” and “being open” about mental health, which are not bad things. However, those two things are not enough to end the mental health crisis. “Mental health awareness,” which we have had plenty of already, is also not enough.
As Mike Smith of the International Mental Health Collaborating Network wrote in his article for The Guardian, “If we accept the concepts of parity of esteem [i.e., valuing mental health the same as physical health], then we should describe not stigma, but rather bigotry, hatred, unlawful and unjust discrimination.” He is right. And although he does not mention it, there is already a word that concisely pinpoints “bigotry, hatred, unlawful, and unjust discrimination” against survivors of mental illnesses: sanism.
The priority in mental health and suicide prevention movements should not be to “reduce stigma” or “start conversations” around mental health. Mental health organizations have banked on that rhetoric for ages, and yet the overall suicide rate is still moving upwards. The CDC reported that in 2022, 49,449 people died by suicide, the highest number of suicides ever recorded in the U.S. And at a rate of 14.3 deaths per 100,000 individuals, 2022 had the highest suicide rate since World War II. The suicide rate had never been that high since 1941, where the suicide rate was 15 deaths per 100,000 individuals. This is clearly an issue that needs much more extensive actions than conversations alone.
Also, it is well-meaning to talk about sharing resources. However, alongside existing barriers to care, not everyone has had supportive experiences with suicide prevention resources. For example, there are survivors and people who sought assistance for a survivor who reported unaffirming experiences with the 988 phone number and other suicide hotlines. And upon the launching of the 988 number, some social media users warned folks to not call that number, as someone who is seriously considering suicide could face state violence. While emergency services are rarely dispatched after calling 988 (less than 2% of the time according to SAMHSA), it is indeed possible to face state violence in the form of police brutality, patient neglect, and drained finances shall emergency services be dispatched. There is a dilemma on whether or not police forces should even be involved in de-escalating mental health crises, as their involvement has had deadly results—the cases of Irvo Otieno and Taylor Ware being two examples. However, the possibility of adverse consequences is not always considered before sharing mental health resources. By all means, resources should be shared, but their quality should be evaluated often. If they are generally unaffirming, they should not be recommended until they resolve their issues.
If the priority should not be on “reducing stigma,” then what should it be? Simple, it should be to dismantle sanism in all facets of society and enforce human rights for survivors of severe mental illnesses and suicide attempts, including survivors who are unhoused or institutionalized. This means moving away from the word “stigma” and calling out mental health discrimination as “sanism.” It will be an adjustment that makes people uncomfortable, but discomfort signals growth and a commitment to the cause.
Using the term “sanism” rather than “stigma” is a big step in transforming the mental health and suicide prevention movements into anti-oppressive movements. When the term “sanism” is used rather than “stigma,” we place mental health discrimination in the same realm of severity as racism, classism, ableism, homomisia, transmisia, and all other -isms, and -misias out there. That also means we can concisely and earnestly analyze sanism in intersection with every form of discrimination. Because at the end of the day, no form of discrimination is separable from another. And before reading on, learn why you should use terms like “homomisia” and “transmisia” rather than “homophobia” and “transphobia” here. (TL;DR: It is because having a phobia is not a choice, while having hatred for anything is. Pathologizing hate into mental illnesses is a sanist act.)
Now that sanism’s definition has been given, it is time to break down my Daily Tar Heel article and add some context to different parts. Starting with this quotation from the first paragraph:
“Without pinpointing that dynamic and centering the voices of those survivors, mental health campaigns are running on an “All Lives Matter”-type rhetoric, which does nothing but uphold sanism.”
In this sentence, I am referring to how mental health campaigns have taken generalized approaches to mental health advocacy rather than concisely calling out who is most impacted by the negative attitudes concerning mental health. While organizations have engaged in public policy advocacy as part of their operations, they rarely center their policy efforts in campaigns. The campaigns focus too much on “starting conversations” and “sharing resources,” and not enough on getting people to be activists alongside survivors of severe mental illnesses.
For those who know about the Black Lives Matter movement, “All Lives Matter” has been used as a whataboutism to derail Black-centric dialogues, downplay anti-Blackness, and demonize Black people for decrying racism. The “All Lives Matter-ing” in mental health campaigns is different. Rather than whataboutism, they all but ignore how the mental health system treats people differently in an oppressive system. They will say that “depression does not discriminate” or that “suicide does not discriminate” when depression and suicide DO discriminate. And if you do not believe me, search up the disparities. If depression and suicide did not discriminate, no disparities would exist. But in order to appeal to people’s comfort, such blatant honesty does not occur.
This is an example of respectability politics at play, which banks on appealing to the comfort levels of dominant groups (in this case, people without a mental illness) and widespread society. Many people show up with an “I am here for you” attitude and clock out when the topic of mental health becomes uncomfortable for them. They will say “it is okay not to be okay,” yet draw conclusions about someone’s competence when they get really anxious while presenting or auditioning for a meaningful opportunity. Suppose that person has been diagnosed with generalized anxiety disorder, or even if not, what might they need to feel less anxious? If it is truly “okay not to be okay,” ask them what would help them give their best performance. That does not mean drastically changing arrangements, but such a question could make a big difference in a presenter or auditioner’s performance.
As mental health campaigns keep relying on “All Lives Matter” approaches, they forget that not everyone’s mental health matters to the mental health system or society. Survivors of severe mental illnesses, multiple suicide attempts, multiple psychiatric hospitalizations, and long-term hospitalizations continue to face sanism in the mental health system and society. The same goes for such survivors who have been unhoused or incarcerated. What organizations need to do is commit to anti-sanism, center survivors in their work, and focus on anti-sanism in their campaigns. Enough of “mental health awareness” and making palatability the hallmark of these movements.
As of the time I'm writing this op-ed, the word “stigma” yielded 492 results when searching The Daily Tar Heel’s website. It’s been used to describe attitudes towards mental health, but also those towards free school lunches, black cat Halloween costumes, eating alone and thrifting. Meanwhile, the word “sanism” yielded zero results, likely making this article the first one ever to use it on The DTH website.
I would like to make it clear that the word “likely” is not on my own draft, because there is no “likely” about it. A search of the word “sanism” on their site shows that my article is indeed the first one ever to mention it there. It remains the only mention of that word as of this article’s publication date.
“Survivors can lose job opportunities and friends and familial support, face police brutality, have their bodily integrity violated in psychiatric facilities or even file for bankruptcy after a psychiatric hospital stay.”
Some people might read that sentence and think, you mean bodily autonomy? No, I mean bodily integrity. Make no mistake, the violation of bodily autonomy is also an issue survivors have faced, but I wanted to mention bodily integrity to highlight the realities of forced treatment without consent. Where bodily autonomy is about freedom of choice, bodily integrity is about the right to consent to a choice before its execution. It is worth noting that at least nowadays, there are laws that give patients the right to refuse treatment unless it is an urgent emergency. However, the practice of involuntary commitment remains, and that itself could be considered a human rights violation. If someone is a danger to themselves but not others, should they really be forced into treatment? Note that psychiatric facilities and other institutions have a history of violating the bodily integrity of survivors, especially with the cases of forced electroshock therapy, forced sterilizations, and forced medication.
There are distinctions between bodily autonomy and bodily integrity, with bodily autonomy being about freedom of choice and bodily integrity being about the honoring of a choice made (i.e., not conducting a procedure without the person’s consent). Nevertheless, both are critical to anti-sanism and they must be honored to the fullest extent. When one or both of those principles are violated, that is not stigma—that is sanism.
Speaking of which, there is another thing I want to pinpoint here in this article that I did not have the room to do in my DTH op-ed: “stigma” and “sanism” are not synonymous terms. As previously mentioned, “stigma” is a euphemism for the discrimination survivors of severe mental illnesses have faced. Not only that, “stigma” treats the negative attitudes concerning mental health as separate from discrimination and oppression. Never mind that for every other marginalized group, negative attitudes are considered connected to discrimination and oppression. They are not labeled as “stigmas.”
For example, the American Psychiatric Association published an article titled, “Stigma, Prejudice and Discrimination Against People with Mental Illness.” It is thoroughly detailed on the matter, but here is the problem: one of their subheadings is “Harmful Effects of Stigma and Discrimination.” It is extremely dishonest on the organization’s end to treat negative attitudes as separable from discrimination.
That is what many institutions and mental health organizations have done—they forget that negative attitudes surrounding mental health are connected to systems that oppress certain people and privilege others. In this case, the privileged persons are those without a mental illness and the oppressed persons are those with a mental illness. Also, why not label those negative attitudes as “prejudices” rather than “stigma”? My theory is that using the word “prejudices” rather than “stigma” would make people feel discomfort and guilt. Here is how a Canadian hospital called the Centre for Addiction and Mental Health (CAMH) defines prejudice and stigma: “Stigma is a negative stereotype or negative association about people with an illness. Prejudice is a negative stereotype about a group, such as racism.”
This is a tautology (i.e., redundant statement), because stereotypes and negative associations about people with illnesses are still prejudiced. Why euphemize prejudice with the word “stigma” knowing that stereotypes surrounding illnesses connect to other forms of discrimination anyway (e.g., ableism, racism)? As NAMI Minnesota Executive Director Sue Abderholden wrote in a NAMI Blog article titled “It’s Not Stigma, It’s Discrimination,” “The word ‘stigma’ doesn’t truly reflect people’s experiences with discrimination in housing, education, employment and health care.”
Also, the word “stigma” is too general and can apply to negative attitudes about anything in the world. I can talk about how there is a stigma against dental veneers, botox, or pineapple pizza, because there are negative attitudes surrounding all three of those things. Ever seen people call veneers “chiclet” or “horse” teeth? What about those who mock botox as an anti-aging treatment or cringe at people who like pineapple pizza? Yep, there is so much stigma circulating on those topics and we need to destigmatize those subjects. Who is with me?
Lightheartedness aside, there is one more part from my op-ed I would like to expand on. And it is this one from the last paragraph:
“If mental health and suicide prevention organizations are actually serious about advancing their causes, they should not be focused on ‘breaking the stigma.’ They should be focused on anti-sanism.”
Destigmatization and anti-stigma campaigns focus on “having conversations” and sharing resources, but as previously mentioned, not everyone has the luxury to be vulnerable without the risk of state violence or compromising their social standing. This is especially true for survivors of severe mental illnesses. And again, not all resources are affirming for survivors of severe mental illnesses and suicide attempts, and mental health resources should be evaluated on their quality of care. That is where anti-sanism comes in.
Anti-sanism emphasizes going further than just conversations and the sharing of resources. We must proactively hold everyone accountable for sanism, investigate the quality of the resources, dismantle sanist barriers in institutions, center survivors of severe mental illnesses in envisioning mental health/disability justice, and center survivors of suicide attempts in envisioning suicide prevention. We must demand that mental health and suicide prevention organizations prioritize unwavering solidarity with survivors of severe mental illnesses, suicide attempts, hospitalizations, and long-term institutionalization. Anti-sanism is not a mainstream concept at all, but it should be. Institutions, individuals, mental health and suicide prevention organizations, and all social justice causes should embrace anti-sanism if they expect to actually prevent suicide and resolve the mental health crisis.
As someone who aspires to challenge the sanist status quo in society, anyone who says that I am working to “end stigma” or “destigmatize” mental health is spreading misinformation. I say this bluntly, because again, “stigma” and “sanism” are not synonymous terms. I am only anti-stigma in that I am against the usage of the word “stigma.” I support anti-sanism, and anyone who says that I am working to “end/dismantle sanism,” “fight sanist attitudes,” and “counter sanist stereotypes about survivors of mental illnesses” is spreading facts.
And if I am even more brutally honest here, “stigma” is a very patronizing term. Think about it, when referring to the discrimination of other identity groups, the word “stigma” does not come across well. Do you ever hear anti-Blackness described as “stigma against Black people?” No, because it is not concise and it obscures the severity of anti-Blackness. Likewise, the term “physical health stigma” does not get tossed around much, because there is already a word to describe discrimination against physically disabled people: ableism. Use the word “sanism” rather than “stigma” to describe discrimination against survivors of mental illnesses.
Language matters. If you are not concise about a category of harm and its primary targets, you are making blanket (note: All Lives Matter-ish) statements and being dangerously performative. Continuous usage of the word “stigma” rather than “prejudices” or “sanism” perpetuates the oppression that survivors of severe mental illnesses, suicide attempts, hospitalizations, and long-term institutionalization have faced. In addition, “stigma” has allowed people to disassociate themselves from accountability for how they uphold mental health prejudices and discrimination. That needs to change. While it will bring discomfort, fear, and anger to many people, they need to feel those emotions to understand the pervasiveness of sanism. They need to use those emotions as motivation to engage in anti-sanist activism and decry human rights violations against survivors of severe mental illnesses, suicide attempts, hospitalizations, and long-term institutionalization.
Everyone has a role to play in anti-sanism, and they can start by checking their own sanism. Think about the messages, images, and rhetoric you have seen and even internalized about survivors of severe mental illnesses. Think of the sanist language you use everyday: this entails words such as “crazy,” “insane,” “psycho,” “narcissist,” and even “obsessed.” Understand that such language, messages, images, and rhetoric have influenced mental health discussions, including with euphemisms such as “mental health stigma.”
Instead of saying that something is “stigmatizing” or “reinforces stigma,” say that it is “sanist” or that it “reinforces sanism/prejudice.” “Taboo” is also an acceptable word. Say that subjects about mental health be “normalized” or rather than “destigmatized.” Recognize that it is okay to have critical and uncomfortable dialogues about sanism, and remember: the ultimate goal is to smash sanism out of existence. Use dialogues as catalysts for activism.
And if you need one more reason to use the word “sanism” rather than “stigma,” note that Dr. Birnbaum was inspired to coin the term “sanism” through his conversations with Florynce Kennedy, a lawyer and Black feminist. You may have heard about how Black activists have created blueprints for a lot of social justice movements, and this is no exception for mental health. If intersectionality matters, use the word “sanism,” and see it in intersection with racism and all other forms of discrimination.