A proposed model of dehumanisation and its relevance to dehumanisation in dementia care

The term dehumanisation refers to the ways in which a person is perceived to be less than human or treated as if they are less than human. It involves treating a person as if they are a child or infant, like an animal or non-living object, or as if they are dead, or any other way in which someone fails to be treated like a human being with an adult identity. Dehumanisation is widespread in dementia care; it is a major obstacle to person-centred care and has poor outcomes for people with dementia. This article proposes a new model of dehumanisation. The New Model presents a new way of describing dehumanisation that has been synthesised from current understanding about the phenomenon and reflects what is presently known about the subject. The model aims to summarise existing theories and models of dehumanisation and make dehumanisation theory accessible to students and trainees in healthcare. This article describes the new model, discusses existing models and theories in the literature, and explores the potential role of the new model in solutions for reducing dehumanisation in dementia care.


Introduction
Dehumanisation has a pervasive presence in healthcare settings, including hospitals, clinics, and aged care facilities to name a few. The term dehumanisation refers to the ways in which a person is perceived to be less than human or treated as if they are less than human (Haslam, 2006;Haslam and Stratemeyer, 2016). It involves treating a person as if they are a child or infant, like an animal or non-living object, or as if they are dead, or any other way in which someone fails to be treated like a human being with an adult identity (Haslam and Loughnan, 2014). Research on dehumanisation has grown significantly in recent years, with areas addressed including racism, policing and criminal justice, politics and international relations, and medicine and healthcare (Haslam and Stratemeyer, 2016). Although healthcare has received significant attention over the last decade, unfortunately dehumanisation has been researched far less in the context of dementia care. This gap in the literature is __________________________________________________________________________________________________ Contact: Hana Speering hmcs990@uowmail.edu.au necessary to address as people with dementia are dehumanised in aged care facilities in many ways. For example, age-inappropriate recreational activities are used in aged care facilities that would be better suited to a five-year-old child than an 80-year-old man or woman (Ryvicker, 2009). Providing care or treatment to a person with dementia without asking for permission or providing an explanation (Speering, Speering and Archer, 2020).
Actions such as spooning food into a persons' mouth without warning or asking for permission, or moving furniture around with the person still seated in it, with no verbal acknowledgement given to the person with dementia (Ryvicker, 2009). Excluding the person with dementia from social activities and denying them human interaction are also common examples of dehumanisation in aged care (Brannelly, 2011). Language can dehumanise people with dementia; for example, people with dementia have been described as being "not all there" and "demented" (Swaffer, 2014: 711). Dehumanisation is a critical issue to be addressed as it known to impact health outcomes and reduce the quality of life of the people dehumanised, whereas the implementation of 'humanising' care has been shown to improve the quality of life of people with dementia (Miron et al., 2017;Borbasi et al., 2012).

Summary of Background Theory
Dehumanisation has both cognitive and behavioural components; it describes perceptions and attitudes that are dehumanising as well as behaviours that treat people as less than human (Haslam and Loughnan, 2014). Many causes of dehumanisation have been proposed.
Ageism, stigma, discrimination, prejudice, and stereotypes can give rise to dehumanising perceptions of the target person or group (Dionigi, 2015;Haslam, 2006). Researchers in the medical humanities have explored dehumanisation as a strategy unknowingly employed by healthcare workers to protect themselves against the psychological burden of caring for people who are suffering, and they have also considered how practices in healthcare objectify care recipients (Haque and Waytz, 2011;Boddington and Featherstone, 2018). Time constraints have also been cited by aged care staff as justifications for dehumanising treatment (Persson and Wästerfors, 2009;Boddington and Featherstone, 2018). Furthermore, executive thinking, language, perspective-taking, planning, complex emotions, and selfcontrol characterise the human mind and distinguishes people from animals. Because these characteristics are affected in dementia, these changes may influence how people with dementia are perceived and potentially contribute to dehumanising perceptions. The different ways in which the cognitive and behavioural symptoms of dementia manifest may give rise to different forms of dehumanisation. Symptoms such as diminished cognitive ability, difficulty communicating and reduced awareness, alongside the use of sedatives, could give rise to the perception that people with dementia lack human responsiveness and are more similar to objects than people (Seaman, 2020;Heap and Wolverson, 2018).
Behaviours like spontaneous singing, humming, tapping, crying, yelling, or hitting could give the impression that the person with dementia is irrational, unreasonable, and lacking in selfcontrol, and consequently engenders the perception that people with dementia are similar to children or animals. Furthermore, the care needs of people with dementia might be likened to those of childlike or infants, and consequently the person with dementia may be perceived to be childlike or infant-like (Seaman, 2020). The stereotypes and stigma surrounding dementia means that a person may have negative perceptions about people with dementia before he or she meets someone with dementia. In this case, the disease presentation of dementia could potentially reinforce dehumanising perceptions already held.
More research is needed in this area to establish how the disease presentation of dementia plays a role in dehumanising perceptions.

Overview
The New Model proposes two forms of dehumanisation: positive dehumanisation and negative dehumanisation, with the term positive referring to factors added and the term negative to factors removed. In positive dehumanisation, the person is perceived or treated as having characteristics that are associated with non-human entities like animals or objects, or characteristics associated with children and infants rather than adults. Conversely, in negative dehumanisation the person is perceived or treated as lacking characteristics that are associated with adult people.
Exploring negative dehumanisation first, figure 1 shows negative dehumanisation as occurring when humanising factors are SUBTRACTED from a persons' perceived identity.
These humanising factors constitute the characteristics, values, attributes, or emotions that define as person as a full adult human. To name a few, these factors include values such as privacy, dignity, and autonomy; attributes like sophistication, intelligence, competence, and rationality; and emotions such as hope, joy, love, and pride. Negative dehumanisation involves perceiving or treating a person as if they lack these things and consequently denies the person their adult identity. Denying a person these humanising factors treats the person as if they are less than fully human and is therefore dehumanising.
In contrast, positive dehumanisation occurs when dehumanising factors are ADDED to a persons' perceived identity. These dehumanising factors are the characteristics, values, attributes, or emotions associated with animals, objects, children, infants, or dead people. For example, a person is positively dehumanised when they are viewed as being simple-minded like a child or infant, emotionally inert like an object or dead person, or unintelligent or irrational like an animal or infant. A person is positively dehumanised when the dehumaniser likens the person to something that is not a full human adult and consequently denies the person a human adult identity. In both positive and negative dehumanisation, the dehumanised person is ultimately perceived or treated as something that is not human or less than human.

+ POSITIVE Dehumanisation
Occurs when dehumanising factors are ADDED to a persons' perceived identity.
Involves likening a person to nonhuman entities or children/infants.

-NEGATIVE Dehumanisation
Occurs when humanising factors are SUBTRACTED from a persons' perceived identity.
Involves denying a person their human adult identity.
Manifests when a person is treated like: • An animal or object Manifests when a person is denied or treated as lacking: • Values like privacy, dignity, respect, and autonomy • Human attributes such as sophistication, intelligence, competence, and rationality • Complex human emotions such as hope, joy, love, pride. Note that these two forms of dehumanisation are not mutually exclusive as a person can be subjected to both forms of dehumanisation at the same time. For example, perceiving a person as lacking rationality would be classified as negative dehumanisation, whereas perceiving a person as irrational like an animal or child would be positive dehumanisation when in fact, lacking rationality and being irrational are the same. Also note that the model does not imply any directionality, as dehumanising perceptions may not necessarily precede a persons' dehumanising actions. Behavioural research has shown that a persons' attitude can be shaped by their behaviour -that is, the behaviour is performed first and then the attitude is formed to rationalise the behaviour after the fact (Albarracín and Wyer, 2000). The relationship between dehumanising thoughts and behaviours is likely bi-directional, but this represents an area for future research (Haslam and Loughnan, 2014). Despite these potential issues with the model, the model is still a useful starting point for explaining dehumanisation to students and workers in healthcare. In this framework dehumanisation is defined in terms of the fundamental human values that dehumanisers obscure; a person is dehumanised when any of the eight dimensions are violated. For example, violation of agency manifests as passivity where a person is held passive to their situation with diminished choices and control. Insiderness is violated when a person is objectified, and denying uniqueness results in homogenisation in which differences between people are not respected and the person is treated in same way as everyone else -'oppressed by sameness, routine and repetitious activity' (Todres, Galvin, and Holloway, 2009 consequences that occur when someone is socially excluded' (Galinsky, Wu and Kang, 2005).
To deprive a person of social connection is therefore fundamentally dehumanising. Berdes also considers an earlier model of dehumanisation developed in the context of mental institutions that proposes four 'modes' of dehumanisation: '(1) person as trivium, an adult treated like a child; (2) person as inanimate object, particularly in a passive sense, in which one person becomes the product of another's work; (3) person as animal, that is, a lower or less sensible life-form; and (4) person as other, seen as a nonperson because of physical or mental damage' (Berdes, 1987: 373). This last example especially highlights the role of stereotyping as being a major contributor to dehumanisation.
When reviewing the literature on dehumanisation, two themes become apparent: some dehumanisation is generally a bad thing -they not only simply describe the phenomenon but explain why it is bad for people and societies. However, research has also considered how dehumanisation can serve a protective function, such as in healthcare where dehumanising patients has been found to be mental strategy to protect oneself against the consequences of caring for people who are suffering -for example, to prevent burnout, emotional stress, and psychological trauma (Vaes and Muratore, 2013). Despite this possible role for protection, dehumanisation as a strategy is potentially maladaptive and has poor outcomes for the well-being of the people dehumanised (Haque and Waytz, 2012). Thus, dehumanisation is overwhelmingly framed in the literature as a problem, and the New Model expresses this accordingly by characterising the different aspects of the problem.
In summary, the New Model presents a new way of describing dehumanisation that has been synthesised from current understanding about the phenomenon and reflects what is presently known about the subject. The model is simplified and may not provide full coverage of dehumanisation given how complex the phenomenon is, but nonetheless presents an overview of dehumanisation adequate for training and education purposes in healthcare.

The New Model in Training and Education in Dementia Care
Dehumanisation of people with dementia living in aged care facilities is a major problem in

Other Applications
The New Model is widely applicable to topics beyond dementia care as this section will briefly illustrate. The model can be useful for understanding dehumanisation in contexts such as ageism, racism, and politics. For starters, older people are often dehumanised. For example, consider stereotypes that characterise older people as being frail, senile, lonely, and lacking independence (Dionigi, 2015). Such stereotyping is a form of negative dehumanisation because the older person is painted as lacking human attributes like sophistication, intelligence, and competence. When considering racism through the lens of the New Model, positive dehumanisation is widespread in the dehumanisation of ethnic groups. Research has explored how African Americans have historically been described as excessively violent or irrational, likening these people to brutes or savage animals (Haslam, 2006 There are numerous aspects of dehumanisation that are not yet fully understood and represent areas for future research, but despite these knowledge gaps the New Model has potential for being a tool with high utility in training and educations programs for reducing dehumanisation in dementia care and other settings.
Notes: these authors agree that the term dementia is outdated and support the use of the term major neurocognitive disorder, as defined by the DSM-5. However, the term dementia was used in this paper to help make the content of the paper more accessible to healthcare workers and other readers who are more familiar with the term dementia.