Segregating Schizophrenia

Malcolm X and Martin Luther King, Jr: mentally disordered? (Images courtesy Library of Congress)

“They diagnosed Malcolm X with having schizophrenia, particularly because he was paranoid against the government….And even though it’s incredibly tragic to read this file, you can’t but think like, of course he was paranoid against the government, because the government was profiling him and tapping his phone.”

And yet, the people who diagnosed Malcolm X with schizophrenia weren’t wrong, if they went by the scientific literature of the day.  The highest standards and general scientific understanding of some types of psychosis had, by the late 1960s, been defined in such a way that some kinds of disease were inherently easier to apply to African-Americans.  They were especially easy to apply to African-Americans who took part in the Civil Rights movement or were discontented with the problem they faced in society.

Americans like to think about psychology and mental illness, at least in the 20th century, as “hermetic, clinical encounters between psychiatrists and patients.”  In our show on mental illness, though, Jonathan Metzl reminded us that psychiatric and psychological diagnosis is exceptionally likely to “mirror larger conversations about the psychology of race.”

Prior to the 1960s, schizophrenia and associated diagnoses had been primarily for white women, often ones who exhibited emotional dissociation, not violence or other symptoms.

A Thorazine and Serapsil ads from the 1950s depicting white, female patients.  Image courtesy the American Medical Association Journal of Ethics.

Throughout the 1960s and into the 1970s, both popular conceptions and clinical definitions of many psychiatric disorders and drugs took part in and mirrored the racial dynamics of the period.

Above: 1970s advertisements in a medical journal for an anti-psychotic drug clearly link psychosis with African imagery.  Image from Jonathan Metzl, The Protest Psychosis.

This racialization of schizophrenia can be seen in the story of Caesar Williams.  Metzl told us about him, an African-American man committed to Michigan’s Ionia State Hospital for the Criminally Insane in the late 1950s:

He was given a diagnosis, in the late 1950s, of what was called the psychopathic personality with psychosis. And what I found is that a lot of men like Mr. Williams, who were admitted in the 1950s and diagnosed with psychopathic personality disorder, or antisocial personality disorder….

Williams – whose family was in Redding, California and worried desperately about him – remained incarcerated at Ionia for more than a decade.  According to Metzl,

Mr. Williams’ own voice is largely missing…we know that he mailed three ‘xmas cards’ on December 17, 1962, to Birdie, Susie, and his son…but [when asked by his mother in a request to move him closer to home] according to the institution…her son’s condition remained the same.

As the institution took part in the larger racialization of psychological conditions, however, one thing did change: his diagnosis.

Image: Mr. William’s new diagnosis post-1968, and another African-American male’s clearly altered diagnosis from ‘Psychiatry Personality wit Psychosis’ to ‘Schizophrenia’. Images From Metzl, Protest Psychosis.

According to Metzl, African Americans “found that their diagnosis changed while they were in the hospital. And particularly when the DSM II came out in 1968.”

The new manual – which represented a real attempt to bring scientific progress to the rapidly evolving field of psychiatry – engaged in a very strong redefinition of schizophrenia in particular.  The drive for revision was “grounded in a desire for diagnostic accuracy,” not an active interest in the politics of civil rights and race.  But tied to race they were:

“New terminology, particularly the terms “projection,” “projected anger,” “anger” and “hostility,” these terms became part of the diagnosis of schizophrenia in 1968…”

And these same terms were used – over and over again – to describe the actions of protesters and civil rights activists.  Articles like ‘Six Years of Sit-Ins: Psychological Causes and Consequences’ proliferated and resulted in the creation of a new term – ‘protest psychosis.’  Throughout the 1960s, all these strands increased the ties between African-Americans and the new terms used to describe schizophrenia in the DSM-II.

By the 1970s, the link between African-Americans and schizophrenia was so complete it was showing up in ads like this one, where the imagery of the black power fist, urban environment, and so on are unmistakable:

Image: 1974 Haldol ad courtesy Jonathan Metzl, Protest Psychosis.

And this racialization of schizophrenia was no abstract matter.  It had real consequences for people like Caesar Williams:

“By diagnosing a lot of these African American men, like Mr. Williams, with schizophrenia, they really did increase, not only the amount of time that these men were kept in asylums, but also limited their ability to contest their incarceration, or being kept there…because he had this schizophrenia diagnosis that implied that he was insane, it meant that he stayed in the asylum for quite a bit longer.”

What can we learn from the strange journey of schizophrenia as a diagnosis?  Dr. Metzl has one suggestion:

”..we have to remember the lessons of history, which is that our diagnoses, for better or worse, are shaped by social, and political, and environmental factors. And probably psychiatry more than other specialties.”