The Racial Foundations of American Psychiatry

by Hervé Guillemain
, 28 February 2011

In the United States starting in the 1950s, schizophrenia ceased being a malady of rural and idle whites, to become increasingly associated with blacks coming from the inner cities. This over-diagnosis is related to the struggle for civil rights and the foregrounding of militants who were judged to be aggressive.

Reviewed: Jonathan M. Metzl, The Protest Psychosis. How Schizophrenia Became a Black Disease, Beacon Press Books, 2010, 288 pp.

In 2005, the Washington Post published a scholarly study showing that schizophrenia affected indifferently all ethnic groups in the U.S. However, psychiatrists in the 1980s and 1990s had over-diagnosed this pathology among African-Americans, who had five times more schizophrenics than other ethnic groups. For American psychiatrists, the racial factor seemed always to trump social and individual factors in the genesis of this illness. In this book Jonathan Metzl reconstructs the history of this racial construction of mental illness in the 20th century.

In the preceding century, American physicians had formed the concept of “drapetomania” to stigmatize the behavior of runaway black slaves who were judged to be incapable of any form of freedom. The European concept of “dementia praecox” that spread to the United States around the First World War reinforced the systematic association between crime, immigration, and psychiatric incurability. It was a matter of preventively detecting adolescent schizophrenics in order to neutralize these “born criminals”. But a new vision of this mental illness was also beginning to emerge. Bleuler forged in the 1910s a psychoanalytic interpretation with a more positive image of schizophrenia as the malady of artists, a personality disorder that especially affected whites. When its name changed – from “dementia praecox” to “schizophrenia” – this mental illness was culturally and socially displaced. From an imported and threatening disorder, schizophrenia became between the wars a problem of indifference that was symptomatic of the evolution of Western civilization. The commonly accepted opinion (including by doctors) was that schizophrenia was a white disease, particularly of white women. Anatole Litvak’s film The Snake Pit (1946), illustrates this classic pathology of middle-class women. The sanity of these failing women was expected from psychoanalysis, which was fashionable at the time, or else from using the revolutionary neuroleptics. In the Ionia State Hospital for Criminally Insane (Michigan), whose case files are Metzl’s main source (along with professional journals), this disorder was considered before the 1950s as typical of rural women.

In this renowned institution, the number of woman diagnosed as schizophrenics declined in the following decade. In the first half of the 1950s, the Ionia hospital admitted dozens of new patients coming from the prisons of Michigan, which had been the site of violent mutinies. These rioters, re-labeled as psychiatric cases, upset the demographics of the hospital institution: African-Americans who had represented about 15% of the patients amounted by 1955 to 40%. Of course, medical examinations were contradictory, but they all concluded with the same verdict of “paranoid schizophrenia”. In the space of twenty years, schizophrenia migrated in American culture: it was no longer indifference and passivity that characterized the disease, but rebellion and violence. No longer were the patients white women, but black men. Nor was it rural people who were thus classified, but individuals from the disadvantaged neighborhoods of Detroit. At the end of the 1960s, 60% of admissions to Ionia were such African-Americans.

This “protest psychosis” was theorized in the 1960s and 1970s by American psychiatrists who were rediscovering the racial paradigm in their studies. Research on the subject based on comparisons between black and white groups of patients might have had a secondary effect on the civil rights struggle. In this way, American psychiatry radicalized its theories in tandem with both a) the creation in 1968 of the DSM II (the Diagnostic and Statistical Manual became a worldwide reference in psychiatric matters), which identified the paranoid sub-type of schizophrenia by associating it with bellicose masculine behavior, and b) the rising power of civil rights activists. The initial article by Bromberg and Simon, titled “The Protest Psychosis,” makes a clear link between the civil rights movement, violence, and a form of illusory madness that leads to a rejection of Western civilization. These sick subjects’ focus on a racial antagonism that underlay American society was considered by these authors as a paranoid projection. This aggression, influenced by the speeches of Malcolm X and the Black Muslims, was identified by the professional journals, especially pharmaceutical advertising. The film Shock Corridor by Samuel Fuller (1963) clearly evokes the psychiatric internment of civil rights campaigners. Therefore at the time when the concept of schizophrenia was becoming popular, it was invariably associated with the cause of African-Americans and the threat of national dissolution.

The most surprising thing in this story may lie in the way that Martin Luther King was able to use the term schizophrenia in some of his most famous speeches, and also the way black rappers regularly mention this pathology in their texts. Apart from the integration of racialization into the language, the saddest thing is that when American psychiatry was being deinstitutionalized in the 1960s, the patients who remained locked up were most often these African-Americans who had been considered schizophrenics. Some of them even found themselves in prison when the Ionia Institute was closed in 1977. Another merit of this book is to put into historical perspective the imprisonment of the mentally disturbed at the end of the 20th century due to the re-categorization of schizophrenia as a violent and incurable disease.

The choice of Michigan, a region of major migration and strong racial tensions that was characterized by the internment of “criminals” who were essentially male, might seem to downplay the author’s conclusions. But this would be to forget that the National Institute of Mental Health asserted in the 1960s that African-Americans presented a remarkable proportion of schizophrenic problems, much higher than the white population. It would be interesting to know how schizophrenia was used for political purposes elsewhere in the world in the 1960s and 1970s. We should recall that the USSR at the time resorted to the diagnosis of “torpid schizophrenia” to silence dissidents. Nevertheless, this book, at the intersection of notions of race and gender, contributes in a remarkable way to the history of psychiatry. Without denying the existence of pathologies, it shows the way in which they respond to social and cultural constructions that evolve according to political events and social change. The book is also a healthy invitation to expose the reductive interpretations of mental illnesses and to take into account both the clinic and the culture just as much as biological and mechanical explanations, now so well represented in the new American psychiatry.

Originally published in laviedesidees.fr. Translated from French by Susan Emanuel with the support of the Foundation Maison des Sciences de l’Homme.