The Protest Psychosis: How Schizophrenia Became a Black Disease

by Jonathan M. Metzl

A powerful account of how cultural anxieties about race shaped American notions of mental illness

The civil rights era is largely remembered as a time of sit-ins, boycotts, and riots. But a very different civil rights history evolved at the Ionia State Hospital for the Criminally Insane in Ionia, Michigan. In The Protest Psychosis, psychiatrist and cultural critic Jonathan Metzl tells the shocking story of how schizophrenia became the diagnostic term overwhelmingly applied to African American protesters at Ionia—for political reasons as well as clinical ones. Expertly sifting through a vast array of cultural documents, Metzl shows how associations between schizophrenia and blackness emerged during the tumultuous decades of the 1960s and 1970s—and he provides a cautionary tale of how anxieties about race continue to impact doctor-patient interactions in our seemingly postracial America.


From the Trade Paperback edition.

Genres: Nonfiction, Psychology, History, Race, Mental Health, Disability, Sociology

246 pages, Hardcover

First published January 1, 2010

About the author

Professor and Director of the Center for Medicine, Health, and Society at Vanderbilt University; a Psychiatrist; and the Research Director of The Safe Tennessee Project, a non-partisan, volunteer-based organization that is concerned with gun-related injuries and fatalities in America and in Tennessee.

Reviews

[Thomas · Rating 4 out of 5]

Such an important book for anyone who cares about racial justice and/or mental illness. In The Protest Psychosis, psychiatrist and cultural critic Jonathan Metzl hows how doctors over-diagnosed - and still over-diagnose - black people with schizophrenia. By analyzing archives and oral history interviews from the Ionia psychiatric hospital in Michigan, Metzl reveals how racist people in power portrayed black protestors as mentally ill, in an attempt to medicalize their fight for social justice. He thus draws several astute connections between mental illness, institutionalized racism, and health care.

Mental health is political. It intersects with gender, race, socioeconomic status, sexuality, disability, as well as the forces that oppress minorities within those categories. As an aspiring clinical psychologist, I feel grateful that Metzl approached this topic with such a solid research foundation and a dedication to examining his own methodology's shortcomings. The Protest Psychosis sheds light on many uncomfortable and necessary truths: how psychiatrists and the media perpetuated racist notions of black protest as disease, how doctors perceived women as sick unless they could satisfy a husband, and how even today constructs like race and gender affect diagnoses. Metzl's book urges us to fight against racism and sexism in the mental health field, an area once dominated by straight, heterosexual white men.

While Metzl includes many thought-provoking ideas in The Protest Psychosis, he does a great job in particular discussing retrospective diagnoses and how we must use caution when interpreting the past with our current diagnostic criteria (e.g., trying to diagnosis historical figures with recent iterations of the DSM). Thus, he highlights the role of culture and structures in determining who we perceive as healthy and as ill. He does not discuss schizophrenia's symptoms in great depth, though he does acknowledge the disease's severity, as any psychiatrist would.

Overall, an important book for anyone who enjoys academic writing that intertwines disciplines and applies to the real world. Curious and hopeful to see if this line of research extends itself to more work pertaining to black incarceration and substance use, intersections of race and sexuality and mental illness, and more. Metzl possesses an extensive educational background and intellectual resources to match, and he puts those all to good use in The Protest Psychosis.

[Lawrence Grandpre · Rating 3 out of 5]

Has some strong points in terms of empirical analysis in its discursive analysis of how schizophrenia went from a white women's disease (with terms like "confused, lethargic, depressed" being used as descriptors) to a disease of Black men (violent, noncompliant, murderous).

The author uses a cultural studies, Foucaultian lens which hampers the historical materialist analysis. I've looked multiple times, I can't find a single mention of the FBI counterintelligence program in this book. In a book which tries to answer the question on why Black men might be showing signs of paranoia, this is the sign a near intellectual malpractice. I don't understand why mainstream academics seem to have such inexcusable, gaping holes in their analysis. The material violence against Black men is spin into some abstract, quasi poetic, "Isn't so terrible" affective soup. The concrete material violence against Black men, specifically against the nation of Islam, which figure prominently in this book with Black Muslims specifically targeted with the "Schizophrenia" diagnosis, seems like it should be unavoidable in a text like this. This is the magic of Foucualtianism, the symbolic and discursive nature of the violence becomes more interesting than the actual violence itself, and you get books like this, which could go deep into the action of the Detroit PD which proves Black men were logical in being paranoid about white people and white power, instead they are depicted essentially as noble savages whose madness is almost romanticized within the context of the Foucault inspired, "madness is a revolution state of resistance" frame, a eurocentric frame which is ill fit for depicting the pain and suffering of Black men driven crazy by racism.

For a book of this kind, the research is pretty good. Lots of archival research. Some stunning pictures of advertisements of anti-psychotic medication which pictures Black men and African masks in them. The argument is strong and belivable. But the book can't overcome the structural limitations of the assumptive logic of the author.

[Aggrey Odera · Rating 4 out of 5]

My best friend in college was a man called Pranav Reddy. Pranav is one of those wholesomely brilliant people. In high school, he was the highest ranked Lincoln-Douglas debater in the entire U.S. (he won the Tournament of Champions, the most important debate competition in the country, in 2015). In college, he studied computer science and biology, but could converse brilliantly on any number of subjects, from philosophy, sociology to theoretical physics. On top of all this, though he is full of shit at times, he is the most decent of human beings - warm, compassionate, generous and insanely curious about the world. It was Pranav who got me interested in the subject matter of this book (though the book itself was recommended to me by Lea Eisenstein). During our sophomore year, Pranav took a class with the Sociologist/ Law Professor Dorothy Roberts, and for the rest of the year, all he talked about (which meant all I listened to) was about racism within science, more precisely medical racism.

Roberts’ work focuses on tackling the pernicious assumption that science/ the scientific method is an undertaking free of all the (racial) prejudices that exist in non-scientific society. Scientists, she insists, are social human beings first, and their scientific work necessarily reflects that. “Scientific authority” therefore necessarily needs to be caveated in debate and in cultural conversation, for this authority is often grounded on contestable positions that are socially constructed and maintained. For example, in the U.S., it is a “fact” that, statistically speaking, black people suffer from obesity and heart diseases at higher rates than any other demographic. Understood only as a scientific and mathematical fact, what comes to be necessitated by this situation is a medical intervention, focusing on the eating and exercise habits of African Americans. Understood as a problem that transcends medicine and science however, we might start questioning how social and economic inequalities affect the population rates of obesity and heart disease; how access to information about health, and to the corresponding resources that enable people to be healthy, may mean that black people, as the poorest demographic in the country, are more liable to be affected by obesity.

Another, perhaps more resonant, example: Even in the second decade of the 21st century (I’m not sure if this is still the case today in 2020), there were different tests administered to black people, white people and Asian people when testing for kidney problems (in the estimation of glomerular filtration rates -eGFR - equations). The argument was that black people somehow possessed more muscle mass, white people possessed “normal” muscle mass, and Asian people possessed “less than average” muscle mass. Roberts had two questions when she went to take such a test: 1. Why would she, a woman more than 60 years of age who didn’t lift weights all that much (she's got great arms though!), be thought of as having more muscle mass than a 25 year old Asian woman who was a bodybuilder? 2. Roberts herself is biracial; her mother is black and her father is white. Why, she asked, was she thought of as a black woman with a white father ,rather than as a white woman with a black mother? In which case, why was she given the black test and not the white one?

It has been multiply documented that black people are viewed by doctors as having a higher pain threshold than white ones. The tennis player Serena Williams, for example, almost died of a pulmonary embolism because her doctors refused to believe that the post-partum pain she was expressing was really that serious. The feeling of pain is one controlled primarily by neuroreceptors, and doctors know all too well that the neuroreceptors of black people are not in any meaningful sense different from those of white people. Yet cultural conceptions of pain tolerance, ones that we have inherited from the era of slavery, still abound and impact ways we engage with science and medicine.

As Roberts’ and Williams’ cases show, though race is a social category, throughout history, it’s been made into a medical and scientific one. It is in the genealogy of critique that Roberts engages in that Metzl’s work also participates in. Only he, through historical study, specifically focuses on psychiatry, on how clinical encounters between doctors and patients were influenced by prevailing social conditions, leading to schizophrenia becoming a “disease for black men”.

In the 1850s, slaves who ran away from their masters were diagnosed (by white doctors of course) with drapetomania. This was because the belief was that it was only a mental illness that could lead a slave to do something so ridiculous. In proto-psychological scholarship in the Antebellum South, another common diagnosis for slaves was dysaethesia aethipis, a “form of madness manifested by ‘rascality’ and a ‘disrespect for the master’s property’. This disease that was cured by extensive whipping”. This racialization of mental illness still exists with us today.

As Metzl shows, in the decades preceding the civil rights movement, the mainstream American medical (and popular) opinion considered schizophrenia a disease marked by an inward turn. Schizophrenia was seen as afflicting only intellectuals and white women (akin to the ‘neurasthenia’ that was seen as the affliction of the nineteenth century European intellectual). Schizophrenics were seen as largely harmless to society, and consequently the conditions of their confinement reflected this: lots of open air, encouragement of thoughtfulness, good food, games that involved others etc. The schizophrenic was afforded a gentle paternalism; was seen as someone needing society’s guidance and care, but not one who was dangerous to society.

The civil rights movement in the U.S. became more fiery in the 1960s. From then on, numerous leading medical journals and popular sources, including the New York Times, began describing schizophrenia as a disease not marked by its inward turn but rather by its outwardness; marked not by docility but by rage. It became the disease of “angry black masculinity”. In 1968, the DSM-2 (Diagnostic and Statistical Manual), the principal authority of psychiatric diagnoses in the U.S., was published. Shifting from DSM-1’s characterization of schizophrenia as marked by gentle confusion and depression, the DSM-2 recast schizophrenia as a disease typified by masculine belligerence. From then on, African Americans, especially African American men, were between four and seven times more likely to be diagnosed with schizophrenia, even by African American doctors. As Metzl notes, “From the 1960s onwards, patients described by doctors as African American, paranoid, delusional, and violent had disproportionately high chances of being diagnosed with schizophrenia. Patients described as white, tearful, sad, ruminative, and harmless meanwhile had disproportionately had high chances of being diagnosed with mood disorders or anxiety states”.

Metzl’s work focused specifically on the Ionia State Hospital for the Criminally Insane in Ionia, Michigan. He traces Ionia’s history from the the early 1900s, when it catered to a largely white (and female) clientele of mental health patients, to the deinstitutionalisation that occured in the 1960s, marked especially by the Community Mental Health Act of 1963 (which undercut large mental health institutions like Ionia by diverting funds from them into nonresidential community centers - in mostly white communities- and which thereby led to a mass exodus of mentally ill white patients from institutions into communities where they could be better cared for). A remarkable thing is that most black mental health patients were not deinstitutionalised. A loophole in the act allowed hospitals to continue confining and accepting patients deemed “too dangerous” - and these were invariable black. The conditions in the centers continued to be more constricting, and finally, in 1977, Ionia hospital closed and the site became a fully fledged correctional facility (Riverside Correctional Facility).

The racial demographics in Riverside, like in most prisons in Michigan and the broader U.S., had a disproportionate population of black people. While African Americans comprised no more than 14% of Michigan’s population, 65% of Riverside prisoners were African American.

Today, as Metzl notes, people diagnosed with schizophrenia in the US are far more likely to reside in prisons than in psychiatric care facilities. The rates of schizophrenia in prison populations are five times higher than in the general population. And these people are more likely to be African American men. Metzl’s book very well illustrates the subject of its subtitle - “how schizophrenia became a black disease”, and invites us to investigate not just the assumptions we have that masquerade as scientific while being anything but, but also, more importantly, how our science itself, even when done in good faith, reflects contingent attitudes about race, and what pernicious consequences this can have.

[John · Rating 4 out of 5]

It was sobering reading quotes from psychiatrists’ notes in the 50s/60s containing language that I myself have used in patient notes. This book made me aware of how enmeshed I have already become in the culture of psychiatry, and that really bothered me. There's no doubt that psychiatry has done incredible harm and I feel that books such as these can help me avoid perpetuating those same injustices.

[Samara 1234 · Rating 3 out of 5]

I learned the racist origins of schizophrenia and its development throughout the 20th century. If there’s anything I took away from this book is that how we build structures and systems to define diagnostic criteria can reflect the biases we hold. Such is the case for schizophrenia, where in the early 20th century it was seen as a docile, harmless disease that primarily affected rural, White women. As the Civil Rights Movement progressed, in the latter part of the century, so did the image of who was schizophrenic and what the disease meant. During that time, schizophrenia changed to mean a violent disease prevalent in Black men. In sum, this book highlights how psychiatry, a field at the intersection of natural and social sciences, promoted an unfair and unjust way of seeing a disease objectively, and rather reflected racialized logic backed by flawed ideologies.

I believe that this book is important, especially for social scientists, who intend to create more egalitarian and fair systems, as the author, too, posits.

[C · Rating 4 out of 5]

I liked this a lot, but think it might appeal only to those with a strong interest in institutionalized racism and/or the civil rights movement. It seems more like the kind of book you'd read in a college-level sociology course, rather than one you'd find in the pop-soc section of the library (if that exists).

Coming at this from a physical science and not a social science background, I really appreciated the explanation of how Metzl approached the social science part of the book (e.g., choosing a hypothesis, particular research practices, methods for data interpretation). I also appreciated his caution in pointing out what might (or might not) be appropriate to conclude from the given information and analysis, as well as what is notably absent from the data.

That said, most of the text is spent exploring the historical context of the data, particularly with the help of a small selection of patient case studies. While these make the book more readable to a non-sociologist, the second half of the book references some sociological jargon and concepts that pushed it back the other way. It's a tough balance to strike there between the academic and lay audience, and this book occasionally falls off point.

Regardless, institutionalized racism in the US health care system is a really interesting and crucial topic, so it's pretty cool to see an example of it illustrated in a mostly accessible way. Would probably be great reading for health care workers, particularly as Metzl (who is a practicing psychiatrist himself) also discusses how we might respond to the systemic dysfunction.

[Ngozi · Rating 5 out of 5]

This was a tough read, especially reading the correspondences between family members and the facility. I appreciated the author's personal reflections and acknowledgements. Overall, this book was so engaging. It anticipated some of my questions, and left me to my musings for quite some time after reading a chapter or sometimes a few pages. Vital reading for those who are interested in abolition and disability justice, the consequences of pathologization, and the impact of structural racism within the medical industrial complex. I'll be thinking about and revisiting this book often as I continue my research.

[Sheri · Rating 5 out of 5]

So I read the preface for a class and was interested in the full argument. I went in fully aware that the criminal justice system is the largest provider of mental health in America and believed I understood this to be the unintended consequence of federal funding cuts in the 80s that prevented the development of enough community mental health centers in the wake of deinstitutionalization. I also understood that the system has grown exponentially (particularly through the War on Drugs) and largely serves as a way to contain young people of color (see Michelle Alexander's The New Jim Crow for details). I had even heard that schizophrenia was disproportionately diagnosed in black men. And yet, Metzl was able to surprise me with his storyline of the cultural change in perception of schizophrenia over time.

Metzl gives individual examples from the case files at one (Ionia) hospital in Michigan to show not only how the same symptoms are identified as emblematic of different diagnoses over time, but how the definitions of the diagnoses changed with new additions of the DSM. He uses media (newspaper) portrayals, song lyrics and individual case files to show the change in perspective and meaning that occurs during the civil rights era. During a particular period of threat, institutions (psychiatry, criminal justice, media) re-define sanity and criminality in order to contain the threat.

His choice of hospital is also not random; Ionia was particularly beautiful and welcoming as a mental asylum in the 20s. It was mostly made up of white folks from rural Michigan and provided a rehabilitative environment complete with crafts and sport. By the mid 1950s populations had started to exceed capacity and referrals were being sent from the prison system. The institution itself changed from one of rehabilitation to one of containment as the population shifted from mostly white to higher proportion of people of color. Particularly during the 60s and 70s as the national understanding of schizophrenia changed from that of "grandiloquent genius" to one of "angry black violence" the hospital reacted with violence. By the end of the book, the hospital is gone and the entire complex is simply a prison. Most of the bucolic mental hospitals are gone in the wake of deinstitutionalization; the direct transformation of this one into a prison is a particularly compelling image.

I also really liked his analysis of why everyone (both white and black leaders) identify schizophrenia with the angry black community. White leaders and power structures note the violent behavior as causing a chaotic life; they focus on individual choice (or more often deficit) as explaining why someone has a reaction as well as using it to justify this person's shitty position in society. Black leaders, however, change the frame to note that processing internalized racism in a racist society creates cognitive dissonance and anger becomes rational, understandable, and functional: "instead of a condition caused by civil rights, schizophrenia resulted from the conditions that made civil rights necessary".

He describes the ways in which "medical sources from the 1960s and 1970s suggest that the reality of schizophrenia was also, and at times primarily, shaped by a dynamic whereby the project of helping certain groups of people merged all to easily with the project of controlling them."

Overall this is a really important work and very interesting read for those interested in the intersection between race, mental health, and criminal justice.

Just a few more quotes before I go:
"In this formulation, incarcerating, misdiagnosing, or fearing persons with schizophrenia all serve the larger purpose of subjugating bodies and controlling populations."

"Depression appears a privileged position for those who have time. But schizophrenia is a threat, a crime in progress, and impulse of survival."

"Incarcerating persons with schizophrenia only makes sense if schizophrenia is believed to be a disorder that requires containment rather than reintegration. And diagnosing schizophrenia as disproportionately violent or black only makes sense when using the definition of illness that came of age in the 1960s."

"forgetting is neither random nor innocent. Instead, forgetting is an intensely political act, an act that is requisite for the construction of particular forms of truth."

"the frames aggregating certain symptoms into particular psychiatric diagnoses exist in an ongoing state of flux...psychiatrists should remain continually aware of how social contexts, historical moments, and violent structures shape perceptions of psychiatric reality."

"The notion of recuperation fell by the wayside as hospitals became prisons. Sentences grew ever longer, moats deep, and barbed wire sharper. Empathy gave way to fear, fear to anger, and anger ultimately to indifference."

[Lee · Rating 3 out of 5]

This is the book I've been looking for. It didn't full fill all my fantasies that I had for it, but it was worth reading.

I don't think Metzl is the best writer. I waffled between feeling like his scope was too broad and feeling like his sources were too limited. At times I felt like each chapter read somewhat like a high school English paper, using an only marginally related quote or literary reference garnered from a google search to open the paper.

On the other hand, Metzl situated diagnosis and the psychiatric institution in a social/historical context in a way that is thoughtful, relevant, and an uncommon undertaking. As a psychiatrist himself, he is careful to acknowledge the usefulness of diagnosis and at the same time argues that it is impossible to extricate the process from the social context (at least that's what I think he's saying).

He uses archives and oral history interviews from the Ionia, Michigan psychiatric hospital(now a prison)as a case study to trace the shift in diagnosis of schizophrenia from one of benign, white-middle class femininity worthy of pity and attempts at reintegration to it's current status of volatile, violent, black masculinity needing containment, a process parallel to the 60s and 70s black power and civil rights movements. He integrates (though somewhat clumsily) pharmaceutical marketing and pop culture to illustrate this shift.

From the final chapter: "History thus lets us begin to understand why, in the present day, schizophrenia remains at once pathologized and pathologizing, and signifies both teh need to maintain order and a political imperative to disrupt it...at a particular moment in time, schizophrenia became both a racialized disease and a metaphor of race in the United States."

[Lynn · Rating 4 out of 5]

The author uses Ionia Mental Hospital notes to show how schizophrenia became a white woman’s disease then a black man disease. His theory is a bit fuzzy because the notes are unclear and the evidence hazy. But I believe it. The most damning evidence are the ads for anti-psychotic drugs in the 60s and 70s, showing African masks and idols stating that ancient idols have been taken over by science, Stelazine and Thorazine. Sick and scary.

[Morgan Dhu · Rating 4 out of 5]

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. Psychiatrists instead described patients with schizophrenia as academics, poets, women, eccentrics, and others who perhaps deviated from, but remained largely within, the norm." 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
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.

To be continued

[Anna · Rating 5 out of 5]

One of the best books I have read in long time. Metzl interrogates the intersection of race, psychiatry, and criminality in this beautifully written history of Schizophrenia in America. He tells the story through an institution in Michigan and the patients and employees who cycle through it over time. Through a mix of record analysis, personal documents and interviews, he shows the transition of 'schizophrenia' from a diagnosis most often attributed to disorganized and erratic white women to violent and aggressive black men. At the same time, Metzl tells a story of change in racial relations in America, and white refusal to acknowledge the legitimacy of black rage. Perhaps the most important lesson in this book is the way structures act through individuals. The way well intentioned people become instruments of great evil, while the vulnerable are sacrificed to broad social conflicts and anxieties.

I think this is required reading for mental health professionals. It will help you understand the constructed nature of the diagnoses we distribute, and make you consider carefully the power this gives you.

[Moth · Rating 2 out of 5]

Metzl's research, reported in the book, is undeniably important. Unfortunately, the way he structured and wrote the book was ineffective and at times frustrating.

You may as well read this interview with the author and get all the main points without having to read through dozens of pages (at the very least), including poetic descriptions, before getting to the point.

[Pierfrancesco Mitrotti · Rating 4 out of 5]

La psichiatria, come qualsiasi branca della scienza è fortemente soggetta a revisioni, cambi di prospettiva, capovolgimenti interpretativi, bias culturali. Un esempio ben descritto in questo saggio è quello della schizofrenia, che per gli esperti della salute mentale di oggi è una diagnosi ben precisa, ben differenziabile, con connotati clinici caratteristici, ben definibili da criteri (quasi) universalmente accettati.
Questa stessa percezione valeva negli Stati Uniti degli anni 30 e negli Stati Uniti degli anni 60-70; eppure, leggendo le storie dei pazienti dello Ionia State Hospital for the Criminally Insane estrapolate da quei due momenti storici differenti, ci si accorge della diversità della condizione che porta lo stesso nome, dei prototipi di soggetti affetti, delle diverse implicazioni sociali.
Una donna della middle-class americana, casalinga, "incapace" di portare a termine le aspettative di madre e moglie era facilmente diagnosticata come schizofrenica negli anni 30. Lo schizofrenico di questo tempo non era violento, non era un pericolo per la società, anzi era spesso, nel caso fosse un uomo e bianco, un geniale letterato la cui grandiosità di pensiero rientrava coerentemente nel quadro della schizofrenia.
Un salto di 30 anni in avanti ci porta a confrontarci con un paziente schizofrenico completamente differente: uomo, nero, violento, aggressivo, delirante, paranoide, con intenti distruttivi nei confronti della potente società bianca ("delusional anti-whiteness"). Un corpo nero pieno di proiezioni psicotiche verso i gruppi bianchi.
Come fa uno stesso nome, quello della schizofrenia, a comprendere in tempi diversi questa grande diversità di manifestazione? E come fanno individui con stessi sintomi nelle stesse condizioni a significare cose totalmente differenti in punti distanti del tempo?
Metzl percorre attraverso un' analisi obiettiva degli archivi di Ionia l' imponente evoluzione di un approccio interpretativo, diagnostico, terapeutico e sociale a questa malattia: il viaggio transoceanico del concetto Kaepleriano e Blueleriano di dementia praecox/schizofrenia, la filosofia dei movimenti per i diritti civili legata a gruppi come Black ​Power, ​Black ​Panthers, ​Nation ​of ​Islam, la percezione afroamericana della "propria" malattia mentale, sono solo alcuni degli strumenti narrativi di questo saggio; il risultato è un quadro in cui la schizofrenia non più uno stato da curare e reintegrare NELLA società bianca, ma da respingere e contenere con l' istituzionalizzazione e l' imprigionamento PER la società bianca.
L' autore ci ricorda che la malattia, qualsiasi essa sia, è un evento reale: non è una costruzione storica, ma una costante intersezione di circostanze biologiche che vanno comprese attraverso e dentro le circostanze sociali, culturali, storiche e politiche del tempo in cui vengono affrontate e che l' interazione medico-paziente non è confinata alle quattro mura dello studio ma è plasmata dai fattori strutturali che la circondano.
Noi siamo la cultura che creiamo e la nostra analisi del mondo è il riflesso di tale cultura: non di rado le scienze umane, come direbbe Foucault, possono produrre discorsi e discipline delle "devianze" con l' obiettivo di perpetrare particolari gerarchie di potere con il rischio di generare un destino del malato al servizio non della sua cura ma dell'ideologia dominante.

[Margaret Kirchner · Rating 4 out of 5]

3.5 - mostly because I read this for class. Metzl makes his argument well. At times I think he makes overreaching statements but his basic argument about the transformation from asylum to prison and the correlation between the changing race of schizophrenia diagnosis alongside the Civil Rights Movement is very compelling. I particularly enjoyed the case studies, though it was strange that they were not the stories of real people. I understand the logic behind keeping files private, but making up cases made this less compelling for me.

[Erin O'Riordan · Rating 4 out of 5]

I liked this book because it combined data analysis with science, history, and the humanities. I especially like that the author used a song lyrics database to analyze uses of the words "schizophrenia" and "schizophrenic" in music. This is an interesting and informative work of interdisciplinary scholarship.

I borrowed this book from the public library using the Libby app. I wasn't under any obligation to read or review it.

[Brandon Watanabe · Rating 3 out of 5]

an impressive investigation into the interplay of race and schizophrenia through the twentieth century. a little difficult to follow the logic and hard to read in some sections, but I appreciated the immense attention to detail within the vignettes and the observation of the pitfalls of presentism in historical analysis.

[Dominic Howarth · Rating 4 out of 5]

Concise and brilliantly researched, Metzl never disappoints with his work. A perfect weaving of anecdotes, hard data, and well-written narrative, this book should be read by anyone interested in the prison pipeline and what came before it.

[Hamdi Gzara · Rating 4 out of 5]

في كتابه “قمع التمرد، الطب النفسي ضد الحقوق المدنية: تاريخ من التحكم الاجتماعي”، يغوص جوناثان متزل، وهو طبيب نفسي وباحث في الأنثروبولوجيا الطبية، في أرشيف مستشفى أيونيا بولاية ميشيغان في شمال الولايات المتحدة، ليرصد تطور تمثلات مرض السكيزوفرينيا أو الفصام واستعمالاته المختلفة في سياق التغيرات الاجتماعية التي عرفها المجتمع الأمريكي مع تطور الحركة النسوية وخصوصا حركة الحقوق المدنيّة للسود.

حسب ميتزل، يظهر تأثّر خطاب الطبّ النفسي الأمريكي بنظريات التفوق العرقي للبيض منذ القرن التاسع العشر، حيث نجد في المجلّات الطبية المرجعيّة آنذاك تشخيصات مرضية من نوع Drapétomanie الذي “يصيب العبيد السود وتتمثل أعراضه في التمرّد ومحاولات الهرب من الأسياد البيض!” ، في حين يشكل مرض dysaesthesia aethiopis نوعا من الجنون “يتمثل في عدم احترام مِلكيّة الأسياد”، ويعتبر “الجَلد بالسياط أحد أنجع الوسائل العلاجية المنصوح بها”. وقد استمر أطباء وأخصائيون نفسيون بارزون حتى مطلع القرن العشرين في تكرار أنّ السود غير مؤهلين نفسيا ليكونوا أحرارا.

في مطلع القرن الماضي، وقع التخلّي تدريجيا عن مثل هذه التشخيصات الفجّة في عنصريتها، وذلك بالتزامن مع ظهور مصطلحات وتشخيصات جديدة تطمح لأن تكون أكثر صرامة علمية. في هذا السياق صاغ Eugene Bleuler وهو طبيب نفسي سويسري مصطلح السكيزوفرينيا في 1912 للتعبير عن حالة مرضية تجمع بين جملة من الأعراض من قبيل الهلوسات ونوبات الهذيان واضطراب المشاعر وتراجع القدرات الذهنية. ويرجع Bleuler أسباب المرض إلى انقسام في الجهاز النفسي ممّا ينتج أشخاصا لامبالين، انطوائيين وقد يكونون أكثر قدرة على الخلق والإبداع.

قبل هذا التاريخ كانت أعراض الفصام تُصنف تحت تشخيص آخر وضعه أحد أقطاب الطب النفسي Emil Kraeplein وهو الخرف المبكّر أو Daementia praecox .

الجدل العلمي حول هذين التشخيصيْن وصل إلى الولايات المتحدة مع مطلع عشرينات القرن العشرين. حسب ميتزل، ففي حين لاقت السكيزوفرينيا قبولا رائجا لتوصيف الحالات التي يشخصها الأطباء لدى البيض، فإنّ معظم الأطباء النفسيين واصلوا استعمال تشخيص الخرف المبكر لدى المرضى الذين يعانون بنفس الأعراض، إذ أن الأساس البيولوجي لهذا التشخيص يتقاطع مع تصورات الأطباء الأمريكيين عن دونية بعض الأعراق مثل السود.

هكذا إذًا، يوثّق الكاتب في حقبة أولى تمتدّ من 1920 إلى 1950، حضورا طاغيا للمرأة البيضاء من الطبقة المتوسطة والمثقفين البيض في إحصائيات المرضى الذين يقع تشخيصهم بالفصام. ويُصوّر المرض على كونه اختلالا في المشاعر ناتجا عن حساسية مفرطة للضغط الاجتماعي، تجعل المريض ينقطع عن عالمه المحيط ويعيش بشكل هادئ وسلمي مع تخيلاته وهلوساته.

مع تطور حركة الحقوق المدنية للسود بداية الخمسينات ومع تصاعد نضالاتها وحتى نهاية السبعينات، تتغير الصورة ويصبح الفصامي في تمثلاته النمطية شخصا أسود غاضبا ومتمرّدا يتسم خطابه بهذيان الاضطهاد من قبل البيض، حتى أنّ شركات الأدوية لا تتورع عن استعمال صورة رجل أسود رافعا قبضته على طريق “البلاك باور” black power للترويج لفاعلية أدويتها المهدئة. حتّى أن أحد أعلام الطب النفسي الأمريكي لم يتوارَ عن توصيف الفصام بذهان الاحتجاج (العنوان الأصلي للكتاب بالانجليزية). هذا التكييف الباثولوجي لهؤلاء السود الغاضبين واستعمال تصنيفات الطب النفسي لوصفهم لا يقتصر على المؤسّسة الطبية فحسب، بل يقع استعادته من مناضلي حركة الحقوق المدنية من أمثال مارتن لوثر كينغ ومالكم إكس وغيرهم كدليل على الأثر المدمر لهيمنة البيض على نفسية السود، وفي هذه الحالة يتحول الفصام إلى تمظهر طبيعي ونتيجة حتمية للهيمنة والقهر الذي يخضع له السود.

يتقصّى الكاتب هذه التحولات بالغوص في أرشيف مستشفى ايونيا عبر حالات عيانية لمرضى مرّوا بهذا المستشفى وعبر حوارات مع عاملين سابقين به.

من المهمّ التأكيد على أن الكاتب يتمايز بشكل واضح، عن تيّار معارضة الطب النفسيّ (Courant antipsychiatrique)، فهو لا يعتبر المرض النفسي كوهم أو كخرافة، ويشدّد على وجود أسباب بيولوجية للفصام والذي يصيب 1% من الناس في مختلف المجتمعات. رغم أن المرض يصيب البيض والسود بشكل متساو، فإنّ تمثّلاث المرض واحتمالات التشخيص تخضع لسطوة الخطابات المهينة، بما فيها التحيز المسبق المبني على العرق والنوع الاجتماعي والانتماء الإثني. يدللّ الكاتب على ملاحظته هذه بمقارنة احتمالات التشخيص بالفصام في الولايات المتحدة في وقتنا الحالي، فاحتمال أن يتلقى مريض أسود البشرة تشخيصا بالفصام هي أكبر بـ 4 أضعاف من نظيره أبيض البشرة وهو ما يعتبره كاستمرار لنوع من التمييز العنصري المؤسّسي.

نشر هذا المقال في مجلة المفكرة القانونية- تونس العدد رقم 28

[Jeremy · Rating 4 out of 5]

The schizophrenia rate for African Americans is still 3 times that of Caucasians. If schizophrenia is as heritable of a disease as it has been presented, this statistic should not happen. The author did a great job of showing the importance of structural prejudice in understanding mental illness. He argues that it was not and is not the racist intentions of individual psychiatrists but rather the much larger cultural structural situation that the psychiatrists cannot see outside of.

In my work I am part of a team that is constantly diagnosing schizophrenia and it is very easy to see it as a heritable disease that culture has no say in. But it is also obvious to see that the young schizophrenics are much more likely to be Hispanic than White. And yet I cannot think of a single case where a Hispanic was diagnosed schizophrenic and shouldn't have been. It is only when I take a step back that I can see my racial/cultural bias.

Where the author is weak is his explanation of schizophrenia and symptoms. The people he used as case studies would not be diagnosed schizophrenic unless they were showing signs of psychosis, I.E. talking to themselves or other signs of responding to internal stimuli. He makes it sound like African Americans were being detained because they were angry. While I am sure that happened at times, I imagine most of that population was hidden in jails and not institutions.

Another part of this equation that I don't think got enough attention was the role of illicit substances. Anyone who has worked with the severely mentally ill knows the co-morbidity issue and how it clouds all diagnosis. There are times it is very hard to tell if the psychosis is caused by the drugs, or if the patient is attempting to mask the psychosis with drugs. The issue of chemical dependency treatment and diagnosis with African Americans is a much larger topic again, and it goes perfectly with the author's assertion of the racial/structural blinders that continue to bias decision making in mental health.

[Alo · Rating 2 out of 5]

I feel like this could function as a decent "Institutionalized Racism in Psychiatric Diagnosis 101." But if you have read a good deal of diagnostic criticism, or even important pieces in the anti-psychiatry canon, what he says isn't going to blow your mind. In fact, a lot of the book is unnecessarily stylized and narrative. That is, of course, interesting but a large portion of the book is a presentation of "here is what I found in their archives, what do you see?" He only really goes into depth about the philosophical implications of these examples in the Preface and Conclusion.

The criticism isn't nearly as deep as it could be. Metzl is a psychiatrist and clearly takes pride in his profession even if he is willing to acknowledge parts of its awful history. This is to say that, while he believes we need to be wary of diagnosis in this day in age and take our own preconceived notions about culture into account, psychiatry all in all is on the right track. And well... the book alone surely isn't deep enough to base that conclusion on.

[Talha C · Rating 4 out of 5]

nice exercise in sociology of knowledge. yet at the same time we see just another case in which social transformations are explained within implicit self-containment of civil society by which I mean the argument about "anxieties" about civil rights movement leading racialization of psychic illness completely eclipses state agencies (various security apparati) intervening if not organizing formation of public discourse. such characterizations (anxiety of white middle class) which uncritically psychologizes and emotionalizes what were actually institutional political strategies obscures many politically culpable formations.
no more euphemisms. no more reactionary models which are devoid of any conceptual space to attend historically specific entanglements of state with social processes.

[UChicagoLaw]

Metzl brilliantly traces the racialized process by which the prison ultimately replaced the mental hospital. He digs through these rich archives at the Ionia State Hospital in Michigan and excavates how it is exactly that schizophrenia was transformed from an illness of docile white women to a disorder of black male belligerence. It is really fascinating. - Bernard Harcourt

[Olivia · Rating 3 out of 5]

Super highly recommend for anyone interested in the history of race and mental illness in the US. The writing probably doesn't support recommending it to a wider audience unfortunately. Feels like it falls just short of being an enthralling must-read for everyone,.

[Katrine · Rating 4 out of 5]

Great book, a very nuanced reading of the history and significance of schizophrenia in American history, with emphasis on the intersection between race, gender and science.

[Kate Klein · Rating 4 out of 5]

important!!

[0 · Rating 3 out of 5]

"Defining something as abnormal establishes power relations, and allows those in power to discard, diagnose, or incarcerate threats to prevailing ideologies as transgressive crimes or illnesses. Utterances or actions that signify valid resistance in one context—'Black identification through interest in Islam,' or 'Supports Black Power'—become symptoms of mental illness in another. Foucault held that the human sciences serve as key actors in creating and maintaining this divide. Far from being value-neutral, timeless, or objective, the human sciences discipline particular subjects in order to reify particular power structures at particular moments in time.

Foucault’s arguments apply in obvious instances where totalitarian regimes define political dissent as insanity, and treat it as such. It has been widely reported that the government of the former Soviet Union diagnosed dissidents with schizophrenia before sending them to gulags. And the incidence of schizophrenia rose in China in the period following protests at Tiananmen Square—after all, who but a crazy person would stand in the way of an oncoming tank?

..It is far from happenstance that the category of the angry black male schizophrenic appeared in the charts at precisely the historical moment when angry black men and women protested in the streets, Martin Luther King preached patience while Stokely Carmichael preached revolt, Detroit burned, and the country seemed torn by the racial schizophrenia described by the New York Times. Only in this context did the DSM-II, mainstream American media, and Ionia doctors conspire to define and produce the category of black schizophrenia under the guise of describing it. In other words, defining black protest as insane was far more advantageous than taking seriously the content of that protest, or allowing it to disrupt the functioning of white bourgeois society.

...Blacks demonstrated hostile forms of schizophrenia, the new logic implied, because of their social backgrounds or cultural predilections or because of the biology of their black brains. The new logic located illness, protest, and revolt within decontextualized black bodies, while conveniently overlooking the economic and social injustices that created the need for protest in the first place. Diagnosis, misdiagnosis, and any number of other symptomatic sequelae, were then the result." (157-159)

"(A)s Lacan knew, and Heidegger before him, forgetting is neither random nor innocent. Instead, forgetting is an intensely political act, an act that is requisite for the construction of particular forms of truth. In other words, when read through remnants, incarceration, misidentification, and stigmatization are connected by a logic whereby focusing on the most observable characteristics—the patient, the prisoner, the diagnosis, the molecule, the crime—requires overlooking the historical constructedness of the frames that govern observation in the first place... The black prison that hides behind the water wheel in the William Carlos Williams all-white town. The diagnosis imbued with racial valence long before doctor or patient enters the examination room. Or the structure that, in its structural violence, locks the most needy patients outside the clinic gates so that they cannot even obtain treatment in the first place. In these instances, clinical tensions mask social and political ones. And forgetting not only obfuscates history. It also affords doctors, Ionians, guards, historians, protesters, and others the delusion that they are not themselves prisoners of a rhetorical order, or practitioners of a process of anything but random change over time." (191-192)

"(W)holesale acceptance of psychiatric terms and frameworks involves entry into a potentially racially subjugating symbolic order in which biomedical definitions of illness supplant cultural ones.10 Here, the doctor’s diagnosis serves as the entry point into a cascade of reinforcement. Biomedical diagnoses become requisite for insurance company reimbursement. The longer patients stay in the system, the more diagnoses they accrue. Over time, persons with schizophrenia become doubly stigmatized, both by a diagnosis that carries poor prognosis, and by a medical system that forces acceptance of hegemonic descriptors of well-being at the expense of autobiographies of protest or survival. To enter the doctor’s rhetorical system, rhetorically speaking, is to give up the fight.

All the while, it becomes ever-more difficult to contest the logic of diagnosis itself; or, as Fanon did, to use diagnosis to better understand not the patient, but the society in which he is forced to endure and get ahead. In this sense, even a correct diagnosis is always already a misdiagnosis. And true cultural competence means more than understanding the ways in which difference shapes the expression of symptoms in other people. It also involves recognition of the ways in which we are ourselves symptomatic, doctors and patients both, of a set of enduring negotiations about the meanings of health, illness, and civil rights." (197-98)

[clove · Rating 2 out of 5]

while metzl presents interesting historical analysis of a racialized shift in diagnostic terms, he is not a very strong writer and his sources are extremely scattered, from relevant ads for anti-psychotics in the 70’s, to his own limited studies wherein he over explains methodology as if this were a published research paper rather than historical analysis, to random selections of song lyrics databases. it feels that he’s trying too hard to prove his point- i was already on board when he spoke to the shift in the DSM’s diagnosis of schizophrenia correlating with the civil rights and black power movement, i was on board when you described how this turned schizophrenia from a disorder associated with middle class white suburban women, to associations with urban black men, i was on board when he spoke to how the deinstitutionalization movement led right into the increase incarceration in prisons. his ideas are on point, but presentation is weak and dull.

[Anne]

I read this back in November after it had been recommended over and over again by my criminal law professor (little wonder -- the author cites him several times). It's a worthwhile read for anybody interested in learning more about the history of race-based mental health diagnoses in the US and how these diagnoses do not capture a sad and troublesome reality, but rather perpetuate it.

I appreciated the author's attempts to tell the story around some of the cases he highlights. It made the book engaging and thoughtful. That being said, at times the book felt confused and scattered, committed to making the same point (see above) over and over again in so many ways that I often felt I couldn't see the forest for the trees.

Overall, however, I would definitely recommend this book, especially to medical professionals who struggle with how to excise the racist histories that have informed/produced our current medical system.

[Nuha · Rating 5 out of 5]

Race blindness is nothing new in medicine. It is this persistent idea that we form diagnoses for patients solely based on the presenting symptoms. But symptoms don't occur in isolation, they occur in conjunction with current day life, with political climates, with systemic issues. And oftentimes, system issues such as police brutality can lead to increased paranoia in Black males which is then read as "aggressive schizophrenia". This book is utterly brilliant and painstakingly etched out from archived medical records, medical advertisements, primary interviews and analysis. I loved every second of it. If I had a critique, it would be that Dr. Metzl doesn't go far enough. It is not only schizophrenia that has become racialized over time, but also diagnoses like "conduct disorder" or "antisocial personality disorder".