Natasha Mitchell: All in the Mind on ABC Radio National, Natasha Mitchell here, thanks for your ears. Today an extraordinary historical excavation by a psychiatrist as told in a confronting new book called The Protest Psychosis: How Schizophrenia Became a Black Disease. It's a revealing study of race and mental illness and it's a story that lives on today, really. The latest Count Me In survey by the Care Quality Commission in the UK, for example, has found that ethnic minorities are three times more likely than average to be detained under the UK Mental Health Act in that country.

Well my guest today, Jonathan Metzl, has an interesting hybrid identity as an associate professor of psychiatry and women's studies, heading up the program in Culture, Health and Medicine at the University of Michigan; and the other half of his time is spent seeing patients as a senior attending physician in adult psychiatric clinics.

[Excerpt from Shock Corridor movie trailer]:



The motion picture screen opens the door to sights you've never seen before. Shock Corridor, the medical jungle doctors don't talk about. Case History Number One: Johnny B, brilliant newspaper reporter suffering from hallucinations that his sweetheart is his sister. Case History Number Two: Cathy B, stripteaser, young. Case History Number Three: Robert T, a lone Negro student who stepped out of a white university into a straitjacket. Diagnosis acute schizophrenia.

Well Jonathan, thanks for joining me on ABC Radio National.

Jonathan Metzl: It's wonderful to be here thank you.

[Excerpt from Shock Corridor movie trailer]: Shock Corridor, the incredibly realistic story that reveals the strange intrigues, the criminal impulses, the obsessions that explode into violence.

The story that I tell really does begin in the 1850s and 1860s, there was an illness called drapetomania and another called dysesthesia aethiopis. These were 'invented' by an American surgeon, Samuel Cartwright, and published in surgery journals. And basically what Cartwright argued was that African-American slaves who ran away from their captors must be suffering from a form of illness, because the natural propensity of the Negro mind, as he called it, was towards servitude. And so he argued that Negroes were psychologically unfit for freedom if they ran away, and they had a series of terrible treatments that he associated with that condition. He thought it responded to whipping or bloodletting or other kinds of conditions, but really what he was pathologising was the desire for freedom. This was an idea that really coursed through even American psychoanalytic thought through the turn of the century.

Natasha Mitchell: That somehow a whole population of people were biologically unfit to cope with the pressures of freedom.

Jonathan Metzl: And that if they had freedom they would go insane. So they would do a lot of studies of free blacks and say, oh there's higher insanity in the north and other kinds of findings they couldn't prove.

Natasha Mitchell: It sounds insane to us now, but how prevalent was that belief at the time, how convincing was surgeon Samuel Cartwright's argument?

Jonathan Metzl: What interests me actually is that it was picked up by psychoanalysts and psychiatrists, but I think that whether or not people actually believed the idea, it certainly had a lot of use for people who were trying to maintain certain social and economic institutions.

Natasha Mitchell: Schizophrenia is the focus of your book and you've unearthed what is an incredibly powerful story of how the diagnosis has transformed over the last century in America. Why schizophrenia, why focus on that?

Jonathan Metzl: Well the key reason is that there was a dramatic racial and gender transformation in American medical and popular representations of schizophrenia and that was really the foundation for my study. So what interested me in the beginning was that in the 1920s, 30s, 40s and early 1950s, when the idea of schizophrenia really was coming to America, there was an assumption both in the American popular media and also in American psychiatric journals that schizophrenia was an illness of docile white people very often.

Natasha Mitchell: And particularly women often?

Jonathan Metzl: Many women. So there were popular representations like a film called The Snake Pit from 1948 with Olivia de Havilland. It basically argued that this was a split mind or an insanity caused by the pressures of modern womanhood.

[Excerpt from The Snake Pit]: Virginia, why don't you get dressed, we'll see a doctor.



Doctor? Yes, my head hurts. Robert there's something the matter with my head.



Come on darling, let me help you.



Who are you, why do you torture me, why do you lie to me?



Virginia, what's the matter don't you know me? I'm Robert, your husband.



Let me go, let me go.



Virginia what's the matter.



Let me go, let me go, don't touch me.



Virginia don't you know I love you.



Love me, I can't love you, I can't love anybody.

Also people assumed that schizophrenia was an illness of white male genius and so there was also a lot of articles and studies about a brilliant white male poet or novelist or playwright.

Natasha Mitchell: It was really seen as an illness of the seclusive, sensitive person wasn'tonathan Metzl: Yes this current stereotype of schizophrenia as being an illness of hostility or rage or aggression wasn't part of early representations of schizophrenia. People thought of it more as a split personality, almost a neurotic condition, and that's not a surprise because early proponents of the idea of schizophrenia were psychoanalysts, many of whom were influenced by Freud.

[Excerpt from The Snake Pit]:



How do you feel today?



Very well thank you. Is there any reason why I shouldn't feel well?



No of course not. Where will you go when you leave here, to your husband?



I have no husband.



You haven't? I thought you were married.



I am married.



If you're married doesn't that mean that you have a husband? Oh pardon me, it slipped my mind, what's your name again?



Stewart, Janey Stewart.



Miss Stewart?



No. Mrs Stewart.



Mrs Stewart.



Virginia darling, look at me, don't you know who I am? I'm Robert, Virginia...

As you argue, you think schizophrenia transformed from an illness of what you call white female docility to one of black male hostility. And at the heart of your investigation, Jonathan, is an institution in your own state. Introduce us to the Ionia State Hospital for the Criminally Insane there in Michigan.

Jonathan Metzl: Which was a hospital between the late 1890s and the early 1970s in Michigan, and it was basically the home for people who were convicted of a crime but diagnosed with a mental illness. At its heyday in the 1940s and 1950s it covered an expanse of 450 acres in northern Michigan: big gothic stone buildings, farmland. And access to these archives really provided a human story for the bigger cultural story, because there were dramatic racial and gender shifts in the hospital.

Natasha Mitchell: These records were a gift to you, but they were utterly heart wrenching, weren't they. Describe what those records were.

Jonathan Metzl: They really were state representations, in a way, of people's entire lives, because people would spend so much time in these institutions and so many of the charts were huge volumes of people's—not only doctor's and patient's records and legal proceedings, but also letters back and forth to their relatives, letters from the patients to their doctors, holiday cards, pictures—so you really could tell a whole story of what people's lives were like in that institution.

[Excerpt from The Snake Pit]:



Come on, I said lie down on this table.



How are you today Mrs Cunningham?



You're going to electrocute me.



Was my crime so great?



No Mrs Cunningham nobody is being electrocuted. Dr Sommer and I are trying to make you well. We are your friends.

All of a sudden in the 1960s and the 1970s there's an absolutely dramatic transformation in these same representations where American society suddenly transformed its representations of who got schizophrenia and why.

[Freedom march montage...]

Natasha Mitchell: So we enter Michigan of the 1960s and 70s, and this is where you've found that a major transformation happened. And we are in a town; this hospital is in a town just 130 miles from Detroit. Remind us of the major upheaval that was going on at the time.

Jonathan Metzl: Detroit was really a locus for many important aspects of the American Civil Rights movement, it was the kind of breeding ground for people who were followers of Malcolm X, the Black Power Movement, Elijah Muhammad had given some famous speeches in Michigan so Michigan really was a very...

Natasha Mitchell: Of the black Muslims...

Jonathan Metzl: Right, of the black Muslims. So it really was an important ground for auto workers, people who'd had bad experiences with the penal system, and of course a large African-American community. And so what was interesting for me was tracking the cases of people who had participated either in the Black Power movement or in the Detroit riots, who for various reasons were diagnosed with schizophrenia and ended up in the psychiatric hospital.

[Malcolm X montage...]: Malcolm X preached for Black Power against Martin Luther King's policies of non violence.



Malcolm X was an extremist who never underestimated his opposition. An eye witness to his murder tells what he saw.



Malcolm X: 'It is criminal to teach a man not to defend himself when he is the constant victim of brutal attack. My reasons for going out on a limb as I had is to try and make white people be shocked awake to some of their senses because if they don't awake, they are going to find out that this little Negro that they thought was passive has become a roaring, uncontrollable lion right at the doorstep, not at their doorstep but right in their house, in the bed, in the kitchen, in their attic, in the basement. And if you know that in time you're going to have to do something about it.'



Malcolm X died violently at a meeting in the presence of his disciples and his wife.

Oh they're such tragic cases, and I do tell the story of quite a few of these people. But one man, Otis James, before anything else he had gotten into some trouble in the housing project he lived in but had straightened his life out, he'd become a great student, joined the military like his father and his brother had, he was being shipped off to Vietnam to fight for his country and he came home on furlough before being shipped off, he was on a bus into Detroit and was walking to the Brewster area of Detroit where he lived, and got into a fight with four white strangers. He was in his military uniform and he was the victim of some verbal abuse, a fight broke out, and some Detroit police officers from the famous Tac squads came, these tactical units. People argue that their provocation led to the Detroit riots and these were very violent police squads. They came into the fight, they broke it up, this man Otis James took a swing at one of the police officers, they beat the living B'Jesus out of him and he ended up going to different psychiatric facilities in prisons, solitary confinement, physical abuse. And at some point one of the prison psychiatrists said this man is delusional, and they sent him to the Ionia hospital.

Natasha Mitchell: But in prison he discovered the black Muslims didn't he?

Jonathan Metzl: Absolutely.

Natasha Mitchell: Actually our description of that scene of the sort of whispers and letters and notes of the black Muslim rhetoric being passed around prisons is incredibly powerful.

Jonathan Metzl: Yes, it was a almost a whispering campaign, people would in these prisons pass back and forth these weathered copies of black power manifestos or the writings of Elijah Muhammad, people were at some of the more hopeless moments in their lives, and you read the letters and memoirs and joining into these groups really gave their life a focus and direction. Thinking that here incarceration was part of a bigger project of protest and that things would actually change. So there was a religious and spiritual but also profoundly political component.

Natasha Mitchell: So Otis became known as Abdul Rasheed Karim, didn't he?

Jonathan Metzl: Yes.

Natasha Mitchell: And he ended up in Ionia in 1969, and did he ever leave?

Jonathan Metzl: Well in this case one thing I'd say before is that many of the cases that I looked at he hadn't had psychiatric symptoms before he entered the system but he had been, as I say, in solitary for various periods of time, there was a lot of abuse going on in the prison, so over time he started to become what the prison records would call increasingly paranoid. It was clearly in this case probably a survival strategy because people who aren't paranoid when they are in prison probably don't last very long. But he acted out a lot in prison and ended up getting diagnosed with schizophrenia and being sent to this hospital.

Now he'd initially come into the system on a short two to five year sentence but they kept extending his sentence and then when he was diagnosed with schizophrenia and sent to the hospital he became a mental case. And the psychiatrists kept arguing that he was a danger to society and so he ended up spending the rest of his life in institutions and dying there.

Natasha Mitchell: And you've unearthed countless letters that his brother and mother wrote to the institution to try and get him out?

Jonathan Metzl: Right, claiming that he was a political prisoner.

Natasha Mitchell: Which he did himself, didn't he, it's evident from the records?

Jonathan Metzl: Right, really heart wrenching letters between the brother who was arguing my brother is a political prisoner and you need to let him out. And psychiatrists who would argue well he is still exhibiting symptoms of mental illness and so of course this case, and others that I talk about, really look at the fine line between political protest and insanity. You know one man's symptom is another man's survival strategy or protest, and so it's not like I'm damning the psychiatrists, I am damning the institution that couldn't see what was going on here.

The psychiatrists if they were diagnosing by the book they would say well this man is having hallucinations, this man is having paranoia etc, so I think that in the records of the psychiatrists they weren't thinking this man is protesting society so we're going to keep him, they were saying here's what our profession tells us is the illness and we're trying to treat that illness.

Natasha Mitchell: Now records indicate that the diagnoses given to women at Ionia eventually began to be relabelled. The symptoms described were the same but the diagnosis of schizophrenia was literally crossed out in their case notes and replaced with depression, and when the wave of deinstitutionalisation began in the 1970s women like that left. Ionia eventually became a prison, not a hospital, but African-American men stayed, as did their diagnosis.

This is ABC Radio National's All in the Mind going global on Radio Australia and as podcast, Natasha Mitchell with you, with psychiatrist Professor Jonathan Metzl, author of The Protest Psychosis.

It's very easy to cherry-pick the data from a set of hospital records like this one. You know I guess we need to step back and think well these people were working in a particular time and place with a particular understanding of their profession and how to diagnose. So how did you caution against sort of going in and looking at those records with a particular argument in mind?

Jonathan Metzl: In a way we make a decision when we do research, which problems we are going to look at and which ones we don't. But I'll say in the case of the hospital charts that I look at I, along with my research assistants, looked at over 600 charts from the hospital, randomly selected from an extensive 40-year period of time and so I feel very confident that the demographic trends that I talk about and the diagnostic trends were true to the shifts that were actually happening in the hospital itself. But I also do oral history interviews with people who were guards or attendants, or doctors at the hospital; I look at bigger cultural scripts and cultural stories.

Natasha Mitchell: The Civil Rights movement was afoot but there were big changes unfolding in the clinics of psychiatrists at the same time too, wasn't there? Because we had the publication of the second edition of what was the key diagnostic bible for psychiatrists the Diagnostic and Statistical Manual. How was schizophrenia reinterpreted as you discovered at that time?

Jonathan Metzl: Such an important piece of the story. So the first version of the Diagnostic and Statistical Manual came out in 1952. That manual defined schizophrenia as what was called schizophrenic reaction and it presented it largely as a personality condition almost akin to a split mind, and it talked about the quiet or thoughtful nature of split personality of people with schizophrenia. All of a sudden in 1968 the second Diagnostic Manual comes out, the DSM 2, in the context of probably the most racially charged year in the history of the Civil Rights Movement—1968, where there are many riots, many protests. And also the DSM 2 importantly added language in the paranoid sub-type of schizophrenia, it added several important terms, it said the new criteria included aggression, hostility and projection. These hadn't been characteristics in DSM 1 and the manual explained, 'the patient manifests the characteristics of aggression and hostility and also attributes to others characteristics he cannot accept in himself.

And what I did was basically coded all of the scientific literature at the time and also the charts from the hospital and showed how these terms 'aggression', 'hostility' and 'projection' were for various reasons disproportionally used in the charts of African-American men to talk about the aggressive hostile protests that they were performing in the Civil Rights Movement. Or else ... 'projection' was very important because it's like they are blaming their problems on American society rather than introspecting. So there are all these quiet and silent ways that this new diagnostic term that ostensibly was not racialised had profound racial implications in the 1960s.

[1960s black protest and psychology montage...] : The ugliest and most alarming sounds of '65 were probably those that came out of the dark of the Watts area of Los Angeles on the night of August 14th.



The protest psychosis a special type of reactive psychosis. Archives of General Psychiatry 1966.



Social Conflict and schizophrenic behaviour in young adult Negro males. Journal for the Study of Interpersonal Processes, 1961.



'Psychiatric History and Symptom Differences in Black and White Patients', Journal of Consulting and Clinical Psychology. These considerations suggest that growing up as a Negro in America may produce distortions or impairments in the capacity to participate in the surrounding culture which will facilitate the development of schizophrenic types of behaviour.

Natasha Mitchell: And the language change was enormous. How schizophrenia was described was profoundly different, and in that year you tell the story of New York psychiatrists Walter Bromberg and Frank Simon who described a form of schizophrenia amongst black prisoners that they called protest psychosis, and that's the title of your book. What was protest psychosis?

Jonathan Metzl: Basically they made an argument that I saw not just in my Ionia charts but also in scientific literature, that African-American men who participated in various forms of protest against the state were demonstrating a new form of schizophrenic illness. And so they said either you had to be crazy to participate in these groups, and these groups are kind of magnets for people who are already insane, or participating in these groups is driving black men to insanity. But either way they felt that this was a new face of this clinical condition.

Natasha Mitchell: And they managed to couch protest in a clinical language, so they sort of described people as having a delusional anti-whiteness that the psychosis was coloured by a hostility to Caucasian values and people.

Jonathan Metzl: Absolutely. And so in a way if you are calling this some kind of mental illness you don't have to take seriously what it is that they are actually protesting against. So part of this was a pathologising of political protest and moving it from a political realm to a clinical one.

Natasha Mitchell: And the FBI certainly at one stage I gather diagnosed Malcolm X as pre-psychotic, paranoid schizophrenic. What's interesting, though, is that Civil Rights leaders themselves and their media used the connection between race and schizophrenia to their own advantage as well, claiming that political action was in a sense creating a schizophrenic state of mind.

Jonathan Metzl: Yes, it's not just a top-down story, and so in my research I found 10 or 15 Martin Luther King sermons where on one hand King would talk about schizophrenia as being an ethical choice between good and evil that was part of the African-American mind. And he would say there's a choice within all of us, are we Dr Jekyll or Mr Hyde, are we going to go down the path of anger and hostility or are we going to practise non-violent resistance?

On the other hand Black Power leaders talked about schizophrenia as well. They argued almost the opposite thing, they said well either of course black people are going crazy because they are fighting against a racist system and the only way to fight back is militancy. Or there is a mental illness and that illness is racism. Either way it was a very potent protest trope that showed up across Black Power rhetoric as well.

Natasha Mitchell: Jonathan, pharmaceutical advertisements changed in extraordinary ways too, didn't they? What sort of imagery have you dug up from the era—and I have to say I'm still astounded by some of the images and words that I see in pharmaceutical advertising today. But what did you find at the time?

Jonathan Metzl: Well the images, particularly for anti-psychotic medications, were very powerful. I unearthed a series of advertisements for serious tranquilisers, Haldol, Stelazine, Thorazine that either represented African iconography, so African tribal masks, and would use incredibly charged racial language—so it would say this is the tool of primitive psychiatry and they would show these African masks—or images that quite literally showed, shockingly enough, angry black men protesting in the streets. And there's one image I reproduce in the beginning of the book, it's a Haldol advertisement that shows an angry black man in a burning urban scene who's shaking his fist. And the important point for both of these is that the iconography from these images literally appearing in the leading psychiatric journals was taking directly from the themes of the Civil Rights movement. The kind of Return to Africa Movement played out in these African scenes, and the idea of a clenched fist which was...

Natasha Mitchell: The classic inverted Black Power fist.

Jonathan Metzl: Exactly. Again, it was a replaying of a cultural pathology and trying to tweak it into saying it's a clinical pathology as well.

Natasha Mitchell: It wasn't just the imagery, I mean on that inverted Black Power fist ad for Haldol there's the headline: 'Assaultative and belligerent? Cooperation often begins with Haldol'.

Jonathan Metzl: Right, so basically pathologising what it saw as a social condition and morphing it into a clinical one.

Natasha Mitchell: You're a psychiatrist, you work with patients who have schizophrenia; are you arguing to an extent that schizophrenia was a socially fabricated disease for some African-American people?

Jonathan Metzl: On one hand let me say very clearly that I do think that there is a 'real' there of schizophrenia. I think that there are symptoms like delusions and hallucinations and paranoia that are absolutely ruinous to people's lives. I'm very sensitive to that. Psychiatry has advanced greatly since the 1960s in terms of its understanding of possibly the biological factors that might lead to psychiatric symptoms. But I think that particularly in the case of schizophrenia, and possibly particularly with mental illness, there's always a resonance between clinical biological factors and social and cultural factors. And what I argue is that even though we have the fantasy that we can separate those two, we are actually doing a better job for our patients and understanding ourselves and our profession if we can understand not just biology but the ways that biology is situated within moments of cultural context.

Natasha Mitchell: So how does this relationship between race and schizophrenia that you've unearthed over the last, well, 100 years, play out today?

Jonathan Metzl: Actually studies since the 1960s have shown that black men in this country are diagnosed disproportionately with schizophrenia at rates of four, five, six, seven times greater than other groups, over-diagnosed with schizophrenia and under-diagnosed with conditions such as depression or anxiety or bipolar disorder. Now this is a real aberration of what we think of, because schizophrenia ostensibly is a biological illness that should occur in all peoples at the same rate—there's no racial or genetic basis to this.

Natasha Mitchell: Well the great figure that we hear is that 1% of the population has schizophrenia across all countries and cultures. You suggest that that 1% itself is a delusion.

Jonathan Metzl: Right, you could say why is it that black men are being over-diagnosed with schizophrenia? It's in part about attitudes but it's also partially about how we define the illness itself. Part number two is this is the origin story for a criminalisation of mental illness that's happened in the United States, and of course there are many factors that play into that. But if you live in a state institution and you're diagnosed with schizophrenia in the United States in the present day, the chances are exponentially greater that you are going to be in a prison than in a hospital, and part of it was this transformation that I feel is represented by this Ionia hospital, it becomes, I think, a potent metaphor for this change in our understanding of schizophrenia from an illness that's one that is non-threatening to an illness that really threatens the fabric of American society.

On one hand there have been very important moves in medicine to at least train doctors to be more culturally aware or culturally sensitive. But if you look at these problems over time you see that they are much more reflective of bigger structural issues about the ways we frame certain diagnoses, the ways we allocate healthcare resources, the ways in which structural racism plays a part in shaping who ends up with a psychiatrist in the first place and whose suffering is left out on the street. While it might be important that doctors become culturally competent, I also feel that psychiatry as a profession needs to become structurally competent and engaged, or even more engaged with the structural forces that really shape people's experience of the mental health system.

Natasha Mitchell: And Foucault would love you for that. Jonathan Metzl, I think this book is extraordinary and I hope the profession reads it. Thank you for joining me on the program.

Jonathan Metzl: Thank you it's been my great pleasure.

Natasha Mitchell: And Associate Professor Jonathan Metzl's latest book is called The Protest Psychosis: How Schizophrenia became a Black Disease, published by Beacon Books. And I've popped a few more clips of audio from the interview I did with him on the All in the Mind blog, which is where some great discussion unfolds amongst you each week as it does directly now on the All in the Mind website abc.net.au/rn/allinthemind Click on this week's edition and head to 'Add Your Comment'. Transcripts, audio and more there too. Thanks to studio engineer Joel Church, I'm Natasha Mitchell, catch you next week..