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How Psychiatry Mistreats People of Color

There’s a deep mistrust between communities of color and the mental health field.

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In 2005, the  Washington Post published a wide-ranging series on the role of culture in mental illness and told the story of a case encountered by Dr. Roberto Lewis-Fernandez. While completing his psychiatry training at a hospital in Massachusetts, Fernandez encountered a suicidal 49-year-old Puerto Rican woman who begged for help to resolve a conflict with her son. The woman also said she was hearing voices, seeing shadows, and felt invisible presences. At first, the Harvard-affiliated doctors diagnosed the woman as depressed and psychotic. She was given medication and sent home.

“I wasn’t sure if she was psychotic, but I treated her as if she was,” Lewis-Fernandez told the  Post.

But Lewis Fernandez, who’s also Puerto Rican, found the diagnosis unsettling and thought the hospital had misjudged the situation. He knew that at a certain level, seeing shadows and sensing presences was considered normal in some Latino communities. After another argument with her son, the woman nearly overdosed on the medication. She was taken back to the hospital where she was re-evaluated, given a less severe diagnosis, and given help to reconcile with her son.

Race and institutional definitions of insanity share a long and troubling history. Metzl outlines in his book that in the 1850’s, American psychiatrists believed that runaway slaves suffered from an acute mental illness called “drapetomania.” The era was also littered with references to “dysaesthesia aethiopis”, a form of madness characterized by disrespect for the slaver owners’ property and best treated with extensive whipping.

In the early twentieth century, American psychiatrists thought that schizophrenia patients were largely white, middle class and harmless to society. The disease was misunderstood as one that was deeply emotional and, in turn, associated with melancholy housewives, novelists, and poets. In 1935, Metzl notes that the New York Times speculated that many white writers demonstrated a symptom called “grandiloquence”, a propensity toward flowery prose then thought to be “one of the telltale phrases of schizophrenia, the mild form of insanity known as split personality.”

It wasn’t until the 1960’s that societal attitudes toward the disease dramatically shifted. Schizophrenia was no longer seen as harmless, but was instead a dangerous disease defined by rage and associated with the Civil Rights and Black Power movements. In 1968, while protest movements became more radical — particularly those in poor black neighborhoods, the field  of psychiatry introduced a radically new definition of the disease. That year, the Diagnostic and Statistical Manual (DSM) updated its definition. “The patient’s attitude is frequently hostile and aggressive and his behavior tends to be consistent with his delusions.” 

Metzl makes the argument in his book that the change on societal attitudes was the unintended consequence of growing white anxiety about cultural and social change. And while obvious bias can’t be easily discounted, sometimes misdiagnoses are the unintended side effects of persistent cultural misunderstandings. Metzal argues that racial tensions are structured into clinical interactions long before doctors and patients meet in the exam room. 

In the early 1970’s a series of influential studies established the fact that people of color were often over-diagnosed with much more severe mental illnesses than their white counterparts. When psychiatrist miss the mark so consistently, one obvious side effect is that persistent — though perhaps less severe — mental illnesses often go untreated. 

Metzl notes that black men are historically underdiagnosed with illnesses like depression, anxiety, and attention deficit disorder.

“There’s a mistrust of psychiatry that I think is very well-founded. In the 1960’s we see very clearly that psychiatric experts were pathologizing civil rights protests and particularly black power protests as being insane. And it’s very hard to turn around from that and say, ‘Oh no, we made a mistake, please trust us.’ If you have a history of pathologizing legitimate political protests as mental illness, you set conditions for mistrust on both sides.”

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