At the peak of the civil rights movement, notable activists such as Stokely Carmichael, Malcolm X, and Martin Luther King, Jr. garnered national and international attention as they vehemently opposed segregation and protested for the equal rights of Black Americans. The nation was on fire, literally and figuratively, as resistance turned into riots and impatience with the progress of racial equality gave way to a by any means necessary mantra. According to professor, psychiatrist, and cultural commentator, Jonathan M. Metzl, it was also during this time that medical psychiatry came to view schizophrenia as a disease rampant amongst Black men.
The Protest Psychosis: How Schizophrenia Became a Black Disease, is a thought-provoking analysis of how, within the sociopolitical context of the 1960s and 1970s, the intersection of race and mental health altered the way that schizophrenia was diagnosed, understood, and treated in the United States. Once considered a nonthreatening disease that primarily targeted White middle-class female populations, Metzl provides a historical exploration of the means by which schizophrenia became associated with the perceived hostility, rebellion, mistrust, and violence of Black men during the civil rights movement. This association continues to influence collective attitudes on mental illness in the Black community. Part historical case study and part social commentary, Metzl utilizes the complex history of the Ionia State Hospital for the Criminally Insane in Ionia, Michigan to showcase the detrimental impact that shifting definitions of schizophrenia had on Black men.
The Protest Psychosis consists of twenty-seven chapters that are grouped into six parts. Part One introduces the reader to Ionia State Hospital for the Criminally Insane, which was founded in the late 1800s. According to Metzl, Ionia State Hospital predominantly housed White residents diagnosed as suffering from mental illness. However, during the 1950s to 1970s, the hospital population became increasingly Black and male. Despite the Community Mental Health Act of 1963 and various bills passed in Michigan that reclassified and deinstitutionalized patients once deemed criminally insane, Metzl notes that Ionia continued to admit and restrain many Black men who were considered a danger to the community. He insists that this was accomplished by changing their diagnoses from that of less severe mental illnesses, to racially politicized diagnoses of 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" (p. 94).
In Parts Two-Five, Metzl supports his contention by sharing the stories of four residents who, at some point between the 1940s and 1970s, were housed within the Ionia State Hospital; one White female resident (Alice Wilson) and four Black male residents (Cecil Peterson, Octavius Greene, Caesar Williams, and Rasheed Karim). Through a detailed review of patient charts and newspaper articles as well as interviews with former hospital employees, Metzl enhances the reader's understanding of each patient's diagnosis within the transitioning political environment of the civil rights movement. The language used by doctors to diagnose each patient was clearly biased, in that it showed greater empathy being given to Alice, while perceptions of aggression, paranoia, and arrogance were attributed to the Black male residents. Though the detailed stories of each patient give texture to the content of the book, it appears that Metzl took a great deal of editorial liberty in his descriptions which, at times, resemble fiction. I found this distracting as a reader.
In the final parts of the book, Metzl describes the transition of the Ionia State Hospital for the Criminally Insane into to a prison. In 1977, the hospital closed its doors and was replaced by the Riverside Correctional Facility. Metzl highlights the similarities that the prison continues to share with the hospital. Though readers may initially be inclined to blame the intentional or unintentional racist behavior of the psychiatrists for the mistreatment of Black male residents at Ionia State Hospital, Metzl encourages readers to dig deeper into the societal influences that informed the actions of the individual physicians. Metzl contends that racial assumptions, tensions, and biases are historically "structured into clinical interactions before doctors or patients enter examinations rooms" (p. xi), and continue to remain "embedded into the very DNA of healthcare delivery systems" (p. 202).
The Protest Psychosis skillfully crafts a clear connection between the discriminatory perceptions of schizophrenia as a disease prone to Black men and the continued pathologization of Black men and women within a healthcare system that relies on language that has been shown to oppress. In the midst of the social angst of the civil rights movement, the second edition of the Diagnostic and Statistical Manual (DSM) was released. Metzl asserts that the language of the DSM-II, released in 1968, was not racist but operated as such because it unintentionally reflected the social tensions of the 1960s and equated protest with mental illness (p. 98).
The DSM-II gave rise to the substantiation of medical articles, theories, and modes of diagnosis that characterized the rebellious actions of Black men as evidence of schizophrenia, which in turn provided validation for prejudicial diagnoses and scholarly research while reinforcing public misconceptions of the dangers of mental illness in Black men. This new characterization was circulated through mass media advertisements for psychotic pharmaceutical drugs, news coverage, and magazine articles that "explicitly suggested that mental illness resulted not just from conditions of poverty, prejudice, and segregation, but from political attempts to change them" (p. 117). During this time, medical journals rediscovered previously ignored Black populations as research subjects and classified rebellious activity such as that of the Black power movement as an example of the hostility of mental illness, specifically schizophrenia. The most notable of theories to develop was Walter Bromberg and Franck Simon's protest psychosis; the condition after which Metzl chose to title his book.
Protest psychosis, as defined by Bromberg and Simon, is a condition which views Black male participation in activities, such as the civil rights movement, as a contributing factor for aggressive and volatile schizophrenic symptoms in the Black community. Protest psychosis has long been contested for its racist and accusatory overtones. According to Metzl, however, the damage done by its assertions is evidenced in society today. Through his research, he illustrates the connections between incarceration, stigmatization, and mental illness in that "people diagnosed with schizophrenia in the United States are far more likely to reside in prisons than in psychiatric care facilities" (p. 187). Finally, Metzl concludes that examples of the stigmatized perceptions of schizophrenia that link aggressive behavior to mental illness can still be heard in the politically rebellious lyrics of hip hop music. Unlike Bromberg and Simon's protest psychosis, however, hip hop lyrics portray mental illness as a response to societal inequities and not as a condition acquired by attempts to change those inequities.
Metzl's professional commitment to the field of psychiatry is apparent in that he makes no qualms about his recognition of schizophrenia as a real biological illness or the medical advances that have been made in the field. It is because of this commitment, perhaps, that he fails to make any mention of disability studies in his analysis. While he is critical of the medical model of disability and the DSM, he does not acknowledge disability studies as a leading field of thought for such critiques, nor does he recognize his interdisciplinary approach as characteristic of disability studies. This omission could also explain why the text falls short of providing an activist-oriented critique and, instead, lends itself to a call for institutional reform and specialized practitioner training. For disability studies scholars, this can prove to be the greatest weakness of the book.
Historical instances such as the Tuskegee experiment inform the cultural mistrust of institutional forms of healthcare services that exists in the Black community (Ward et al, 2009). With his book, Metzl adds another layer to our understanding of this mistrust and the factors that contribute to its persistence. Metzl's style of writing solidifies his authority as a thorough historical academic, empathetic psychiatric practitioner, and culturally conscious investigator. The Protest Psychosis is a text that can easily be applied by faculty in classes ranging from history, psychology, sociology, or race studies. While there is no direct reference to disability studies, I do believe that this is a text that should be of interest to disability studies professionals because of the broad-based critique of the Diagnostic and Statistical Manual(DSM) and medical model of disability that it provides.
Ultimately, The Protest Psychosis is a passionate call for re-envisioning the perception of schizophrenia. He urges readers to consider the social, political influences that impact how mental illness is perceived and understood. He implores current and future professionals in the field of psychiatry to commit themselves to being self-reflective practitioners who are conscious of the racial assumptions and ethnocentric biases that they may take with them into their doctor-patient relationships. The Protest Psychosis is an insightful reminder for us to never stop asking questions of ourselves as professionals and researchers. It is also a reminder that more work is needed to truly pull back the layers of context that go into our understandings of mental illness. In essence, The Protest Psychosis is an interdisciplinary text that is inherently aligned with the assertions of disability studies because it asks questions of a society that has deemed certain human anomalies as abnormal while adhering to an exclusionary idea of normality. This is a fascinating and valuable text for anyone who is interested in a historically sound exploration of how language, race, and sociopolitical context influence the ways in which mental illness is defined.
- Clark, L.O., Heidrich, S., & Ward, E.C.(2009). African American Women's Beliefs, Coping Behaviors, and Barriers to Seeking Mental Health Services. Qualitative Health Research, 19(11), 1589-1601.