Jonathan Metzl's The Protest Psychosis: How Schizophrenia Became a Black Disease is an examination of how institutionalised racism and social constructs of "abnormal behaviour" have influenced the changing psychiatric definitions of certain mental illnesses - specifically schizophrenia and the now out of fashion dementia praecox - and resulted in a situation in which "... African-American patients were 'significantly more likely' than white patients to receive schizophrenia diagnoses, and 'significantly less likely' than white patients to receive diagnoses for other mental illnesses such as depression or bipolar disorder."
In noting that black men entering treatment (voluntarily or otherwise) for mental illness are far more likely to receive a diagnosis of paranoid schizophrenia than any other racial group, Metzl argues that allthough "Everyday racism seems a reasonable explanation for these findings," the situation is actually more complex. In the preface to his book, Metzl states:
This book makes a broader claim: from a historical perspective, race impacts medical communication because racial tensions are structured into clinical interactions long before doctors and patients enter examination rooms. To a remarkable extent, anxieties about racial difference shape diagnostic criteria, healthcare policies, medical and popular attitudes about mentally ill persons, the structures of treatment facilities, and, ultimately, the conversations that take place there within.
Focusing on how the diagnosis of schizophrenia was used to classify people admitted to Ionia State Hospital in Michigan from the 1940s onwards until it closed as a mental institute in the late 1970s, Metzl examines the changing use of this diagnosis. Initially given primarily to nonviolent white criminals and distressed housewives - who were seen as ill but not dangerous - by the 1970s it was predominantly assigned to black men supposedly characterised by "masculinized belligerence."
In his book, Metzl looks at the origins and evolving definitions of schizophrenia in the context of social changes, and particularly racial politics and the civil rights movement in the USA, especially in Detroit which was part of the catchment area of Ionia Hospital. As Metzl notes:
American assumptions about the race, gender, and temperament of schizophrenia changed beginning in the 1960s. Many leading medical and popular sources suddenly described schizophrenia as an illness manifested not by docility, but by rage. Growing numbers of research articles from leading psychiatric journals asserted that schizophrenia was a condition that also afflicted "Negro men," and that black forms of the illness were marked by volatility and aggression. In the worst cases, psychiatric authors conflated the schizophrenic symptoms of African-American patients with the perceived schizophrenia the civil rights protests, particularly those organized by Black Power, Black Panthers, Nation of Islam, or other activist groups.
As Metzl further comments in the preface:
As but one example, the title of this book comes from a 1968 article that appeared in the prestigious Archives of General Psychiatry, in which psychiatrists Walter Bromberg and Frank Simon described schizophrenia as a "protest psychosis" whereby black men developed "hostile and aggressive feelings" and "delusional anti-whiteness"
after listening to the words of Malcolm X, joining the Black Muslims, or aligning with groups that preached militant resistance to white society. According to the authors, the men required psychiatric treatment because their symptoms threatened not only their own sanity, but the social order of white America. Bromberg and Simon
argued that black men who "espoused African or Islamic" ideologies, adopted "Islamic names" that were changed in such a way so as to deny "the previous Anglicization of their names" in fact demonstrated a "delusional anti-whiteness" that manifest as "paranoid projections of the Negroes to the Caucasian group."
Metzl further quotes Bromberg and Simon on the 'sypmtoms' of this protest psychosis: “antiwhite productions and attitudes. . . . It becomes apparent that the intellectual dissociation represents in part a refusal to accept the syntactical language of standard English. . . . Often the prisoners draw pictures or write material of an Islamic nature, elaborating their ideas in the direction of African ideology with a decided ‘primitive’ accent. . . . The language used may be borrowed from the ancient ‘Veve.’ . . . Bizarre religious ideas are Moslem in character, either directly from Mohammedan practice or improvised.”
Key to Metzel's argument is the fact that "... the rhetorics of health and illness become effective ways of policing the boundaries of civil society, and of keeping these people always outside." Marginalised groups have historically been characterised as more likely to be diseased or defective, either physically or mentally, and discontent with society or one's assigned status in it, no matter how merited, as a marker of mental health issues. Metzl lists some of the ways in which this has manifested or been observed with regard to both political dissidents and racialised groups, points particularly pertinent to an examination of the psychiatric labelling of black makes during the 1960s, a period of civil rights activism and black power movements that combined both political protest and a heightened presentation and awareness of racial discontents.
Scholars have long argued that medical and governmental institutions code threats to authority as mental illnesses during moments of political turmoil. Much of the best-known literature on the subject comes from outside the United States. International human rights activists such as Walter Reich have long chronicled the ways in which
Soviet psychiatrists in so-called Psikhushka hospitals diagnosed political dissidents with schizophrenia. Meanwhile, Michel Foucault often cited French hospitals as examples to support his belief that the discourses of the human sciences produce and discipline deviant subjects in the larger project of maintaining particular power hierarchies. Foucault also importantly developed a theory of "state racism," whereby governments use emancipatory discourses of what he called "race struggle" as excuses for the further oppression of
minority groups. Meanwhile, the Martinique-born psychiatrist Frantz Fanon called on his experiences in Algeria to describe a North African syndrome in which political and medical subjugation literally
created psychiatric symptoms in colonized subjects. Fanon's important schema, discussed at length below, focused on the ways in which racist social structures reproduce themselves not only in political or economic institutions, but also in the "damaged" psyches of people it needs to control.
As Metzl notes, however, the history of ascribing specific kinds of mental illness to black patients predates the civil rights movement by a considerable length of time. He notes the early history of the diagnosis of mental illness among blacks in America, which usually worked in support of
... existing beliefs [that] "Negroes" were biologically unfit for freedom. This troubling argument emerged from the work of American surgeon Samuel Cartwright, who wrote in 1851 in the New Orleans Medical and Surgical Journal that the tendency of slaves to run away from their captors was a treatable medical disorder. Cartwright described two types of insanity among slaves. Drapetomania resulted when "the white man attempts to oppose the Deity's will, by trying to make the Negro anything else than 'the submissive knee-bender' (which the Almighty declared he should be) by trying to raise him to a level with himself, or by putting himself on an equality with the Negro." According to Cartwright, such unnatural kindness led to a form of mania whose sole symptom was the propensity of slaves to run away. Similarly, dysaesthesia aethiopis, which is Cartwrights term for the "rascality" and "disrespect for the master's property" that resulted when African Americans did not have whites overseeing their every action. Cartwright theorized that both conditions resulted from biological lesions and he advised treating both with whipping, hard labor, and in extreme cases, amputation of the toes.
Metzl includes in his arguments a brief overview of the development of the understanding of schizophrenia as a mental illness. Originally known as dementia praecox, one school of researchers characterised the disease as "... a biological illness caused by underlying organic lesions or faulty metabolism ... [that] resulted from irreversible biological changes..." Others theorised that dementia praecox "...was not a biological disorder, but was instead a psychical splitting of the basic functions of the personality." This splitting "...was accompanied not by violence, but by symptoms such as indifference, creativity, passion, and even fanaticism." This theory led to the use if the term schizophrenia, from the Greek words for "split" (schizo) and "mind" (phrene).
Metzl notes that the differences in theorising about praecox as opposed to schizophrenia resulted in the condition being interpreted very differently based on the psychiatrist's beliefs concerning its etiology. Those who followed the idea of schizophrenia as an illness of personality instead of biology tended to describe patients in terms that "...remained largely, though by no means entirely, free of connections to violence, invasions, crime, impurity, and other eugenic staples." Patients with schizophrenia were in general not seen as dangers or as threats, but as persons needing nurturing in order to find the "sensitive and tender nature" hidden behind a patient's "cold and unresponsive exterior." Leading clinicians "... advocated teaching patients how to function as adults through activities that substituted 'objective The reality for phantasy' such as occupational therapy, physical exercise, and the encouragement of participation in 'dances, concerts, and other opportunities for social contact.' "
Those who understood schizophrenia to be essentially the same as the organically caused dementia praecox, however, were more likely to see it as a racialised disease:
... in 1913, Arrah Evarts, a psychiatrist from the Government Hospital for the Insane in Washington, D.C., wrote an article in the Psychoanalytic Review titled "Dementia Praecox in the Colored Race" in which she described dramatic increases in the illness in "colored" patients.
.... Evarts linked the appearance of praecox in these and other patients to the pressures of freedom - pressures for which "Negroes," she argued, were biologically unfit. Speaking of slavery,
Evarts wrote, 'This bondage in reality was a wonderful aid to the colored man. The necessity of mental initiative was never his, and his racial characteristic of imitation carried him far on the road. But after he became a free man, the conditions under which he must continue his progress became infinitely harder. He must now think for himself, and exercise forethought if he and his family are to live at all; two things which has [sic] so far not been demanded and for which there was no racial preparation. It has been said by many observers whose words can scarce be doubted that a crazy Negro was a rare sight before emancipation. However that may be, we know he is by no means rare today.'
However, as the clinical use of the diagnosis of dementia praecox declined and the conceptualisation of schizophrenia as a disease of personality became the prevailing one, this tendency toward a racialised diagnosis declined. As Metzl points out, "Prior to the civil rights movement, mainstream American medical and popular opinion often assumed that patients with schizophrenia were largely white, and generally harmless to society."
As the civil rights movement and other events highlighting the unrest among black people in this the U.S. entered the consciousness of the public and the psychiatric profession alike, a shift began to appear in the perceptions of mental illness. Metzl notes that the release of the revised Diagnostic and Statistical Manual of Mental Disorders (DSM-II) in 1968, on which many symptoms of mental illness were seen as maladaptions to the patient's environment, both reflected and in some ways codified an understanding of schizophrenia as a violent disorder commonly seen among black patients. By the 70s, anti-psychotic drugs marketed for treatment of schizophrenia were often advertised with imagery that suggested angry black men, inner city tensions, or "primitive" thought processes - the latter imagery often suggesting or openly using traditional African art or artefacts.
In examining the language used to discuss research into psychiatric conditions beginning in the 60s, Metzl observes that "... data analysis suggests that authors of research articles in leading psychiatric journals preferentially applied language connoting aggression and hostility to African Americans during the 1960s and 1970s. The spike in such associations raises the specter that the DSM-II codified ways of talking about blackness in addition to talking about mental illness. To be sure, the DSM claimed to seek neutrality. But, in the real world, doctors and researchers used the manual’s charged language to modify, describe, and ultimately diagnose the category of black under the rubric of the category of schizophrenia."
This developing construct of schizophrenia as a disease of blacks led into madness by hostility and delusions triggered by the "antiwhite" ideas of prominent black leaders was not limited to psychiatric circles. Increasingly during the 60s, the media began using the imagery of schizophrenia and psychosis to discuss racial unrest among blacks in America.
For instance, an electronic newspaper archive search for articles with the terms schizophrenia and schizophrenic in combination with terms such as Negro, racial, civil rights, and, by comparison, with Caucasian, feminism, and Equal Rights Amendment, reveals a series of significant numeric trends starting in the late 1950s. As but a few examples, the electronic archives of the New York Times, Los Angeles Times, and Chicago Tribune show the terms Negro plus schizophrenia or schizophrenic returned 36 results dated 1930 to 1955 and a staggering 259 results dated 1956 to 1979. A search for Negro plus paranoid or paranoia similarly returned 12 results dated 1930 to 1955 versus 358 results dated 1956 to 1979. Caucasian or white plus schizophrenic or schizophrenia returned no results from 1930 to 1955 and only 1 from 1956 to 1979, and feminism or women’s rights plus schizophrenia or schizophrenic returned no results from 1930 to 1955 and 10 results dated 1956 to 1979.
Metzl goes on to note the way in which this imagery of schizophrenia was used to differentiate between "good" blacks, who did not raise anxiety in mainstream, white, society, and "bad" blacks, who were angry and appeared poised to destroy the social order: "Schizophrenia also provided a framework for dividing civilized blacks from unruly ones, the Martin Luther Kings and Jackie Robinsons who espoused nonviolence from the LeRoi Joneses, Stokely Carmichaels, and Rap Browns who did not."
During this period, the black press, and black leaders and theorists, also adopted the psychiatric imagery of schizophrenia, but for them it was seen in reverse. Rather than categorising the revolutionary black man as violently mentally ill, and his protest, his frustration and his anger as the symptoms of his disease, black writers saw the situation of a black man living in a white supremacist society as the cause of a kind of survival schizophrenia and revolution the healthy road to a cure. "In their pages, schizophrenia also became a rhetorically black disease. But, instead of a condition caused by civil rights, schizophrenia resulted from the conditions that made civil rights necessary. Civil rights did not make people crazy, racism did. Instead of a mark of stigma, schizophrenia functioned as a protest identity and an internalized, projected form of defiance."
It is when Metzl turns his attention to his historical research into the medical files of hundreds of patients at the Ionia State Hospital, originally known as the Michigan Asylum for Insane Criminals, which operated between 1885 and 1976, that we see the real-life consequences for black, primarily male patients.
In looking at the charts of schizophrenic patients from earlier time periods, prior to the beginnings of the civil rights movement, he found that these patients were not seen as particularly violent. While a minority of patients were described as hostile, suspicious or paranoid, these patients were most frequently described as confused, withdrawn, and cooperative. Further, differences between the symptoms of white and black patients with schizophrenia were for the most part insignificant; black patients were more likely to be suspicious, white patients to be suicidal.
Further, it was the assumption that patients, even those remanded to the Hospital because they were classified as criminally insane, were to be treated with the eventual goal of recovery and release. "During the ﬁrst half of the twentieth century, the idea that even criminally insane persons might improve with treatment and return to their lives functioned as a viable concept. The goal of institutions such as Ionia was not merely to warehouse people, but to recuperate them."
In examining the medical records of Black men admitted in the 50s and early 60s and diagnosed with various personality disorders, Metzl observed that these diagnoses were often changed to one of schizophrenia in the late 60s and early 70s, even though the other contents of the records made it very clear that there had been no change in their symptoms, no new manifestations of disease. Despite the move toward deinstitutionalisation of the period, which led to the downsizing and eventual closing of many hospitals for the mentally ill, these black men were considered dangerous and were among the few patients kept in custody. Indeed, when Ionia Hospital was finally closed, this same group of black men were transferred to another facility for the dangerously insane. At the same time, white women who had been admitted with diagnoses of schizophrenia were being re-diagnosed with depression and released to the care of their families.
Metzl makes it clear - and quotes extensively from representative case files in so doing - that the black men in treatment at Ionia Hospital were not healthy persons unjustly confined. Rather, he is exploring how the ways in which the assessment of the men's condition, and their prospects for release, were affected by changing ideas about blackness, illness and violence.
This is not to suggest that many of the men did not suffer from debilitating mental anguish—indeed, the men lost lives and dreams and loved ones, and were often deeply in need of treatment and care. But the associations implied by that anguish changed over time. In institutional terms, “Negro symptoms” such as hallucinations, delusions, and violent projections came to mean different things. ... Thus did African American men at Ionia develop schizophrenia, not because of changes in their clinical presentations, but because of changes in the connections between their clinical presentations and larger, national conversations about race, violence, and insanity.
Metzl concludes with a brief exploration of the way in which imprisonment has replaced commitment to care facilities for those who enter the justice system with a mental illness.
Many mental-health professionals feel that something is deeply wrong with a system that incarcerates so many mentally ill persons, or that posits prisons as primary treatment centers. The illnesses themselves too often become life sentences. Symptoms so frequently get worse, and the prison rhetoric of containment precludes improvement, recovery, or reintegration. We are not apologists for crime. Yet, most mental-health providers believe that even nightmare scenarios, in which mental illnesses contribute to criminal acts, demonstrate the importance of treating such illnesses proximally, in the community, rather than distally, after the deed is done.
The notion of recuperation fell by the wayside as hospitals became prisons. Sentences grew ever longer, moats deeper, and barbed wire sharper. Empathy gave way to fear, fear to anger, and anger ultimately to indifference. “Everything changed when mental health was taken over by Corrections” was a refrain I heard again and again during oral history interviews with staffers who worked at Ionia during the transition to Riverside. “Corrections told us to stop caring for people,” an elderly gentleman who worked as an attendant told me, “even though in some cases we had these people in the hospital for years. Corrections made clear that our job was just to keep them quiet. No one gave a damn about their needs."
This is a difficult but important book, especially in the current rising wave of racial unrest that may well presage a second wave of revolutionary human rights activism among people of colour. One of the most important take-aways from this book for me has been how psychiatry and white fear interacted to reinforce the caricatured social image of black people as violent savages - which is the exact racist imagery that both triggers and is used to excuse the violence against black bodies and black lives we are seeing all around us. This is one part of how these images gain credence and blot out the truth.