Mental Disorders and Dehumanization: A Systematic Review

Background: The concept of dehumanization keeps pace with human history and means the denial of humanness to another human being. Purpose: The aim of this review is to study the literature in the field of mental health to investigate the existence of dehumanization. Method: A literature review was conducted from 2002 to 2022 using keywords in Google scholar, Pubmed, PsycInfo and Scopus Databases. Results: It seems that there are some mental disorders that have dehumanizing characteristics. Also the way the diagnostic manuals of mental disorders are used (DSM-5), the communication between specialist-patient, the labels and the stigma of the mental illness, the biogenetic explanations of the mental disorders and the characteristics of the psychiatric clinics. Conclusion: The literature review shows that patients with mental disorders experience dehumanization and therefore measures should be taken to prevent and limit the phenomenon.


Introduction
There is sufficient evidence for a negative attitude towards people with mental disorders (Rao et al., 2009;Angermeyer et al., 2011). People with mental illness often report experiencing negative perceptions among mental health staff about their prognosis, which are partly related to "physician bias" (Thornicroft et al., 2007). These attitudes lead to discrimination in many areas, including the workplace and housing, and to rejection by family and friends (Zhu et al., 2017). They can also lead to reduced life satisfaction and decreased self-esteem, increased alcohol use, depression and suicide (Parcesepe & Cabassa, 2013) through expected and real discrimination and self-stigma (Vogel et al., 2013;Mak et al., 2014;West et al. 2015;Krendl & Freeman, 2017).
Research findings show that health care workers also show a reduced return on humanness for patients (Trifiletti et al., 2014;Vaes & Muratore, 2013;Lekka et al., 2021;Lekka et al., 2022aLekka et al., , 2022b. The use of dehumanization as a coping strategy to protect oneself from the burnout and anxiety caused by daily professional contact with patients with psychiatric disorders shows how dehumanization can work (Fontessea et al., 2019;Lekka et al., 2021). However, even if dehumanization presents certain functional parameters for mental health workers, the potentially detrimental consequences for patients justify our attention (Haque & Waytz, 2012;Lekka et al., 2022a).
The dehumanization in the hospital settings was the subject of Ms. Lekka's doctoral dissertation and for this reason it was carried out in depth. The aim of this review is to study the literature in the field of mental health to investigate the existence of dehumanization. The choice of this topic was made due to the many years of work of Ms. Lekka in a public hospital in Greece, with the aim of reducing or eliminating the phenomenon of dehumanization. For this reason, below is an extensive study of the existing literature aimed at improving health services. The foundation of focusing on specific aspects during analysis was the fact that previous studies have found that there is a correlation between the factors we study (mental disorders, classification systems, communication, labels, stigma, biogenetic explanation and psychiatric clinics) and dehumanization.

Mental Disorders and Dehumanization
Mental disorders can reveal distortions of social perception. A person with a disorder may have difficulty understanding others or fail to fully recognize mental states in others, while in more severe cases they may give life to inanimate objects. In short, the disorders themselves have features of dehumanization and self-dehumanization.
Perceptual distortions not only have consequences for sufferers and society as a whole, but can also help in understanding the etiology, diagnosis and treatment of psychopathology. Research findings show that: 1) Autism spectrum disorder is characterized by decreased agency perception in adults, 2) Schizotypy is characterized by increased agency perception and experience in entities that are generally thought to have no mind, 3) Psychopathy is characterized by a reduced perception of experience in adults, children and animals. These results suggest that the characterization of psychopathology should focus not only on the minds of sufferers, but also on how their minds perceive the minds of other people and entities (Gray & Wegner, 2010;Gray et al., 2011;Gray et al., 2012).

Classification Systems and Dehumanization
The classification system of mental disorders, namely the Diagnostic and Statis-tical Manual of Mental Disorders (DSM-5) emphasizes the idea of "mental illness" with more and more behaviors being labeled as brain diseases. Before making a diagnosis, the social context in which the examinee lives should be taken into account because many times the problems in the living conditions that are accompanied by anxiety are medicalized, hiding the role of environmental factors at the expense of human development, freedom and dignity.
The DSM-5 provides more diagnostic categories than the previous one, which means more labels for mental illness. This has an impact on humans (Cambril, 2014), social and economic implications (Pickersgill, 2014) as well as includes a wide range of comorbidities (Regier et al., 2009;Hyman, 2010;Regier et al., 2013). The multiplicity of diagnoses (541 vs. 383) in the DSM-5 (Kontaxakis & Konstantakopoulos, 2015) leads to the medicalization of normalcy, increases the cost of medical care as well as the stigma of mental illness (Frances, 2009). The DSM not only influences how doctors diagnose and treat their patients, but also how insurance companies decide what conditions to cover, how pharmaceutical companies plan clinical trials, and how funding agencies decide which research to fund (Miller & Holden, 2010).
Psychiatric diagnoses have served as powerful tools to exercise harmful social control so the diagnosis should be made for the benefit of the patient. Regularity is an endangered species. In this new world few will go through life without mental disorder. All the proposed new diagnoses will extend the psychiatric diagnosis to its vague and difficult boundaries with normalcy. The result will be the involuntary medicalization of normalcy with consequent over-treatment, stigma and misallocation of scarce mental health resources (Frances & Widiger, 2012). Unfortunately, discrimination and prejudice against those diagnosed with a mental disorder remain a concern (Estroff et al., 2004).

Communication and Dehumanization
Studying human history, it is understood that in order to survive, man must communicate. Its main feature is the human relationship that starts from relating. A review study shows a gap in communication between clinicians and patients with mental disorders (Milton & Mullan, 2014). Lack of effective communication may contribute negatively to the early diagnosis and treatment of mental disorders, increased stigma and marginalization of the mentally ill, and ultimately to their dehumanization and self-dehumanization (Lekka et al., 2021;Lekka et al., 2022aLekka et al., , 2022b. Poor communication at the time of diagnosis is confusing and stigma anxiety has been reported as a reaction to diagnostic news (Gallagher et al., 2010). Martinez et al. (2011) found that the labeling of mental illness results in patients being perceived as animals, increasing perceived risk and motivation for social rejection. Research findings show that people consider themselves and others less human when they are socially excluded (Bastian & Haslam, 2010) probably because the degree to which we experience ourselves and others as having substantially human qualities may depend on human interconnection (Haslam et al., 2005).

Labels and Dehumanization
People with the tags of mental illness belong to an underrated social category. The work of Harris & Fiske (2006) suggests that one mechanism that governs responses to people with mental illness may be the degree to which those who perceive them attribute human status to them. Thus the label "mental illness" alone can affect the signs of humanity in a person who bears such a label. In another study, when people treat a person whose behavior is within the norm and has a favorable state of recession, the label mental illness can shift dehumanized tendencies in the opposite direction (Martinez et al., 2011). The dehumanization of self and others may be the result of a cognitive focus on painful experiences that are critical to the perception of human life (Sakalaki et al., 2017). Research findings also show that psychotic patients are more dehumanized than healthy people, but see themselves as more human compared to neurotic patients (Svoli et al., 2018;Lekka et al., 2022a).

Stigma and Dehumanization
The crisis for people with mental illness is often shaped by their behaviors, but this does not reflect their entire existence. With a distorted collective identity the stigmatized person is reduced to the mind of others in an infected, discounted individual (Overton & Medina, 2008). Stigma refers to an individual or a group of individuals who must be distinguished from the norm, they must be labeled as having an undesirable difference (Goffman, 1963). Human stigma can also lead to dehumanization, where the individual's humanity is reduced to a point where he or she is perceived as inhuman, as a person who has no "inner life" (Haslam, 2006;Bastian & Haslam, 2010). The stigma towards mental disorders has decreased, but remains high (Lally et al., 2013).
The second theory of stigma is self-stigma. Self-stigma is an internal evaluation process according to which people judge themselves. This crisis could be the result of messages received from social norms, but eventually the individual creates the crisis towards himself. This decision lowers self-esteem. Negative stereotypes associated with the stigma of mental illness can have serious implications for self-esteem (Blankertz, 2001). When people with mental illness realize that they do not have a support system they are dehumanized. The stigma imposed by others raises the expectation that people with mental illness are unable to meet the responsibilities that are part of daily life (Overton & Medina, 2008).
Self-stigma also appears to be associated with the level of treatment adherence among people with schizophrenia and its negative effect has been found to intensify during the self-stigma process (Fung et al., 2008). Unfortunately, stigma occurs at multiple levels simultaneously: intrapersonal, interpersonal, and structural (Corrigan et al., 2014).
The results of a meta-analysis show that the social rejection of the mentally ill has remained alarmingly stable over the past 20 years, although citizens' knowledge about the biological correlations of mental disorders has increased. The association of mental illness with biological factors does not seem to be a means of addressing the stigma and discrimination of people with mental illness (Schomerus et al., 2012). Because of stigma-related concerns, individuals believe that diagnosis can affect their social identity and relationships with others (Magliano et al., 2008;Thornicroft et al., 2009;Gallagher et al., 2010). In addition, it can cause a strong sense of shame due to their cultural beliefs (Hwang, 2008) or it could lead to treatment abandonment (Seedat et al., 2002). It has been reported that people who hoped for future recovery had a less pronounced perception of emotional and social difficulties as a result of a diagnosis of schizophrenia (Magliano et al., 2008). The stigma was cited as a reason why psychiatrists may not disclose the diagnosis. Users of the service reported lower satisfaction with diagnostic communication, such as information about the specific disease, drug side effects, and treatment options. Qualitative studies have supported this finding as a gap between users' information preferences, services, and service satisfaction (Milton & Mullan, 2014).

Biogenetic Explanations and Dehumanization
Biological explanations for mental disorders are often thought to reduce stigmatizing behaviors by giving the impression that patients do not control their symptoms and thus cannot blame them (Lebowitz et al., 2016). However, research findings have shown that biological explanations are associated with increased stigma trends (Kvaale et al., 2013a). Thus, the recent rise in biomedical interpretations of mental disorders may provoke even more negative perceptions among clinicians (Pescosolido et al., 2010;Schomerus et al., 2012).
Regarding schizophrenia, it seems that biogenetic explanations and diagnostic labels from the public are positively related to prejudice, fear and desire for distance (Martinez et al., 2011). Biogenetic beliefs are related to the perception of danger and the unpredictable, to the fear and desire for social distance. Similarly, most studies have found that public labeling of a disorder or disturbing behavior as a "mental illness" (or a true diagnosis) exacerbates and does not improve prejudice and discrimination (Read et al., 2006). Research data show that the beliefs associated with biological causal beliefs are almost unchanged (Kashima et al., 2005). Because stereotypes about people with psychological problems often have negative content, which is unpredictable and dangerous at its core (Angermeyer et al., 2011), substantive thinking can be particularly destructive by increasing the acceptance of these stereotypes and the belief that are inherent characteristics of the sufferer (Kvaale et al., 2013b).
Research findings suggest that citizens tend to perceive clinicians who support biological explanations of psychopathology as less warm than clinicians who support a more traditional psychosocial perception of mental disorders (Lebo-witz et al., 2015). This is a potential cause for concern, given the importance of warmth in the therapeutic relationship-which in turn is a predictor of patient rejection and clinical outcome (Horvath et al, 2011). If potential patients perceive biologically oriented mental health nurses in this way, such perceptions could further hinder the formation of strong therapeutic relationships (Lebowitz et al., 2015).

Psychiatric Clinic and Dehumanization
Certain features of the architecture and clinical units of psychiatric hospitals (eg small space, noise, dirt, lack of space) threaten the dignity of patients. For example, it can be assumed that standard and common areas undermine patients' individuality and tacitly promote the idea that patients are expendable, which is an important criterion of mechanistic dehumanization (Haslam, 2006). In addition, being locked up for weeks indoors implicitly implies that patients should be monitored like animals in cages, a situation that also conveys a message of dehumanization, as lack of self-control is a well-known criterion of animalistic dehumanization (Haslam, 2006). The fact that mental health facilities are usually less enjoyable or comfortable further demonstrates society's perception of people with mental illness, suggesting that they deserve or need less comfort than other human beings (Fontessea et al., 2019).

Conclusion
In summary, we can say that the dehumanization of the mentally ill is done in various ways, either directly or indirectly, which has costs for the patient, specialists and the health system in general. Explaining in detail the ways in which patients with mental illness are dehumanized, the need for preventive measures to dehumanize patients is considered imperative, which will help improve the effectiveness of care.
At this point, an effective communication with the patient would help him to incorporate the new situation in his life while effectively avoiding social rejection. In addition, it is suggested the design of psychiatric clinics to be more humane, with colors on the walls and comfortable spaces for recreational activities and group meetings. Moreover, mental health professionals should be trained respecting stigma and self-stigma. Finally, compassionate care is recommended, as it benefits patients in terms of adherence to treatment, wound healing, satisfaction and well-being.