Review – Jonathan M. Metzl. The Protest Psychosis: How schizophrenia became a black disease (Beacon 2009)

By Suman Fernando

It is well known that black people, compared to white people, are much more likely to be diagnosed as suffering from ‘schizophrenia’ if they are seen at psychiatric units in the UK or USA. This fact has been commented upon and discussed extensively, and often acrimoniously, in the UK but not discussed much in the USA. If this book does not start the discussion going nothing would – and it is high time that it does. The book by Jonathan Metzl is an excellent and sensitive analysis of one of the most important issues in psychiatry when practiced in multicultural settings and possibly in the mental health systems on both sides of the Atlantic.

The arguments in the UK on what is euphemistically called the ‘over-representation of black people in the mental health system’ has focused on a mixture of racism and insensitivity to cultural differences being the underlying issues affecting psychiatry and mental health services in general. Unfortunately some psychiatrists have vehemently opposed the idea that psychiatry may be racist in any way, seeing this as an allegation that psychiatrists are racist individuals. Others have maintained that it is not individual prejudice of psychiatrists, or indeed any group of professionals, that results in this situation but the racism inherent in the system of psychiatry –its ways of going about its business, the effect that popular stereotypes have on the diagnostic process and so on. The proposition advanced generally is of institutional racism in psychiatry.[1] The people who oppose this institutional racism theory claim that medical research has failed to detect any racism in psychiatric practice and argue that psychiatrists in the UK are not prejudiced, that the system of diagnosis in modern psychiatric practice is ‘objective’ and so not affected by popular images or subtle racism, and that the depiction of psychiatry as racist has resulted in black people with ‘real’ illness losing out.[2]

This book from the USA brilliantly traces the way that the schizophrenia diagnosis has changed according to the influences in society at any given time. The author, Dr Metzl, describes 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. He discusses the changes in the use of this diagnosis against the context of what happened in society outside the hospital – articles in psychiatric journals, images used in pharmaceutical advertisements, the way schizophrenia itself was recast in the (American) Diagnostic and Statistical Manual (DSM) during the 1960s and 1970s and finally, and most importantly, the impact on the schizophrenia diagnosis of racial politics and the civil rights movement in the USA, especially in Detroit which was part of the catchment are of Ionia Hospital. Dr Metzl found in his research that, until the early 1960s, schizophrenia was largely ‘an illness that afflicted nonviolent, white petty criminals including … women from rural Michigan’; but by the mid-1970s ‘schizophrenia was a diagnosis disproportionately applied to …. [mainly] African American men from urban Detroit.’ Meanwhile, the image of schizophrenia in the USA generally was transformed in the 1960s and 1970s from (being seen as) a psychological reaction and splitting of the functions of personality to one of a disorder of ‘masculinized belligerence’.

In various parts of his book, Dr Metzl discusses the history of race and mental illness in the USA – for instance how absconding from slavery was interpreted as a symptom of mental illness given the name drapetomania[3] and how the idea developed during the civil unrest of the 1960s that some beliefs and feelings inspired by ‘Black Power’ represented symptoms of psychotic illness. In fact the main title of the book is taken from the title ‘Protest Psychosis’ given by Bromberg and Simon [4] to a paper they published in 1960s on this topic.

Although much of the book is about the past, Dr Metzl draws some very astute conclusions about lessons to be learned and action that should be taken to minimize institutional racism in mental health systems and psychiatric practice. Arguing that ‘focusing on the individual obscures the impact of the structural’ he points out the limitations of the ‘cultural competency’ approach which he believes ‘practically trains doctors to remain blind to ways in which the diagnoses themselves convey profoundly racial and cultural meanings’. He suggests that psychiatrists need to develop what he calls ‘structural competency’ – i.e. competence in understanding the way systems work and the influence that social context has on the process of diagnosis. However, in trying to reconcile these statements with his view that ‘mental illness is real’, the author tends to get into a slight muddle, perhaps by failing to explain what being ‘real’ actually means. Another problem with the book is that it tends to be a bit repetitious at times and the main arguments are sometimes a little difficult to follow. In fact a concise summary of the arguments presented in the book would have been helpful. But on the whole the book is readable and at times quite gripping.

At an academic level, this book is a major contribution to the history of psychiatry and the effect of race politics on psychiatric practice in the USA. But it has much wider importance: It carries a powerful and challenging message not just for psychiatrists but for anyone associated with the mental health system as structured and developed in Europe and North America – i.e. systems informed by Euro-American psychiatry, especially its process of attributing diagnoses. Also, it is a warning to people outside these regions not to take on trust the diagnostic system of western bio-medical psychiatry that is being spread all over the world as ‘scientific’ and ‘objective’, but to adapt and build their services bottom up, using indigenous ways of understanding the human condition, consistent with the social, cultural and political contexts in different regions and countries.[5]

Suman Fernando is Honorary Senior Lecturer in Mental Health at the Centre for Migration and Social Care (MASC), University of Kent, Canterbury, UK, and Visiting Professor in the Department of Applied Social Sciences, London Metropolitan University. He is the author of, among other books, Mental Health, Race and Culture, 3rd ed. (Palgrave Macmillan 2010).


[1] See Fernando, S. (2010) Mental Health, Race and Culture third edition. Basingstoke and New York: Palgrave Macmillan

[2] Singh, S. P. and Burns, T. (2006) ‘Race and Mental Health; there is more to race than racism’, British Medical Journal, 333, 648-651.

[3] Cartwright, S. A. (1851) ‘Report on the diseases and physical peculiarities of the Negro race’, New Orleans Medical and Surgical Journal, May, 1851, 691-715, reprinted in A. C. Caplan, H. T. Engelhardt and J. J. McCartney (eds.), Concepts of Health and Disease (Reading MA: Addison-Wesley 1981) pp. 305-25.

[4] Bromberg, W and Simon, F. (1968) ‘The Protest Psychosis’, Archives of General Psychiatry, 19: 155-160

[5] Fernando, S. and Weerackody, C. (2009) ‘Challenges in Developing Community Mental Health Services in Sri Lanka’, Journal of Health Management, 11(1): 195-208.

Het Dolhuys and The Madness & Arts Festival (NL)

The city of Haarlem (NL) is currently hosting the third edition of The Madness & Arts Festival (Sept 24 – October 3rd 2010), a festival that focuses on the interaction between art and madness:

Is there a correlation between madness and arts? How do artists acknowledge madness and how does their work influence the way we think about people with psychological disturbances? For ten days, the festival explores these questions within a comprehensive multidisciplinary programme including theatre, dance, film, music, visual arts, literature and poetry. A public meeting and the educational programme open up “madness” for discussion.

The festival site is located next to Het Dolhuys, the National Museum of Psychiatry, and initiator of the festival. There you can meet the artists, drink a cup of coffee with a psychiatrist, eat apple tart from Het Appeltaartenimperium, make your own Rorschach stain, or listen to a daily talkshow with the festival guests.  The Dolhuys also offers a series of daily activities and creative workshops designed for children and young people.

To see the program of the festival, click here.

Book announcement: Laurence Guignard – Juger la folie

Laurence Guignard, Juger la folie – La folie criminelle devant les Assises au XIXe siècle (Paris, PUF, 2010)

Des faits-divers aux réformes pénales, le thème de la folie criminelle est aujourd’hui fortement médiatisé.
L’ouvrage se propose de revenir sur son histoire et de saisir comment, au me siècle, au moment où la psychiatrie prend son essor, la justice a discerné les fous des sains d’esprit, comment elle a appliqué l’article 64 du Code pénal sur l’irresponsabilité des déments et comment, au fil des enquêtes judiciaires et des procès, a pu émerger puis se conclure un “diagnostic judiciaire” d’aliénation mentale.
L’intense effort d’élaboration d’une doctrine de la responsabilité ne résout que très partiellement les multiples difficultés pratiques auxquelles se confronte l’exercice du droit de punir. Du côté de la psychiatrie, les propositions contradictoires et fluctuantes des experts posent autant de questions qu’elles n’en résolvent. Les conceptions neuves de la folie comme la monomanie homicide, véritable folie du crime qui surgit dans le corpus médical autour de 1817, les instincts, l’hérédité morbide ou la dégénérescence, forment en effet autant de limites problématiques à l’exercice de la volonté libre supposée diriger le sujet responsable.
C’est alors la notion d’inconscient, non encore établie, qui travaille souterrainement la médecine mentale du premier XIXe siècle, faisant des salles d’audience un véritable laboratoire du sujet moderne. Dans la lignée des travaux de Michel Foucault, mais aussi de Gladys Swain et Marcel Gauchet, la réflexion porte sur la place croissante de la psychiatrie en justice, et s’inscrit dans l’histoire de la naissance d’un sujet psychique.

Review – DELIGNY Fernand, Œuvres

DELIGNY Fernand, Œuvres, Paris, Edition de l’Arachnéen, 2007, 1845 pages.

L’histoire n’a pas encore décidé si elle retiendrait Fernand Deligny (1913-1996) comme écrivain, cinéaste, éducateur ou antipsychiatre. De fait, le choix n’est pas facile car, dans chacun de ces rôles, il lui est arrivé d’exceller et il suffit pour s’en convaincre de feuilleter l’édition à la fois volumineuse et magnifique de ses œuvres établie par Sandra Alvarez de Toledo. Le Deligny qui devrait plus particulièrement intéresser H-Madness y est particulièrement bien représenté puisque près de 1000 pages sont consacrées aux traces (surtout des écrits mais aussi des montages de photographies et de dessins particulièrement réussis) de projets menés avec des enfants autistes ou assimilés. On relèvera en particulier les textes et les photomontages de ces deux chefs-d’œuvre cinématographiques que furent Le moindre geste (1962-1971) et Ce Gamin, là (1975)1. A noter également la réédition de presque tous les textes qui ont accompagné la « tentative » cévenole, soit la « présence proche » d’adultes sans qualités auprès d’enfants autistes : initiative qui, discrètement, se poursuit toujours près d’un demi-siècle plus tard. Il n’était peut-être pas indispensable de reprendre tous les livres car on y trouve un nombre croissant de répétitions et j’aurais personnellement préféré une réédition du fabuleux roman injustement pilonné La septième face du dés (Hachette, 1980) au laborieux Traces d’être et bâtisse d’ombre (1983)… Mais je reconnais volontiers qu’on peut ainsi suivre l’évolution d’une pensée dont l’intérêt n’a probablement pas encore été pleinement mesuré. Elle nous est désormais préservée dans un écrin et, au-delà du cheminement à partir de l’autisme, l’édition des Œuvres permet de faire le lien entre l’instituteur à l’asile d’Armentières, le directeur du Centre d’observation et de triage de Lille, l’initiateur de la grande Cordée, le réfugié à La Borde et finalement l’ermite de Graniers. Par contraste avec l’écriture de plus en plus ésotérique de Deligny à la fin de sa vie, le fil qui lie ses différents projets est aussi limpide que l’eau de roche qui fascinait tant Janmari : délinquants ou psychotiques, il s’est toujours agi de mettre en place des dispositifs tels que des jeunes pour lesquels la société n’avait prévu qu’une place confinée (en asile ou en prison) puissent trouver l’espace de déploiement d’une existence qui leur ferait aimer la vie. Qui dit mieux ?

Jean-Michel Chaumont

1 Ces films sont disponibles en DVD dans « Le cinéma de Fernand Deligny », http://www.editionsmontparnasse.fr/product?product_id=1003

Arts in Mind Conversation Series (NY)

Arts in Mind is an original series of conversations with leading figures in the literary, visual, multimedia, and performing arts whose work touches on mental health issues. Co-curator of the series and author of Lincoln’s Melancholy, Joshua Wolf Shenk says:

The fundamental connection between human suffering and creative expression is one of the most enduring, and elusive, of human stories. It’s not just that so much piercing and original art springs from minds afflicted with mental illness, but that the arts lend dignity and humanity to the struggles and triumphs of people whose lives are full of hurt. Arts in Mind will be a centerpiece for exploring these connections — and, we hope, the centerpiece of a wide-ranging community that has long been exploring the arts and mental health.

Created by The Austen Riggs Center in collaboration with the Sandor Ferenczi Center at the New School for Social Research, the Art in Mind series kicks off on September 29, with a program entitled Elegies for Our Lost Asylums: a discussion on the restorative use of architecture, space and art, with Christopher Payne and Anna Schuleit.

Christopher Payne’s photography has artfully documented America’s vanishing architecture and industrial landscape. His new book, Asylum: Inside the Closed World of State Mental Hospitals (with an essay by Oliver Sacks) follows a 7-year exploration of America’s vast and largely abandoned state mental institutions. The New York Times called Asylum one of the best art books of 2009 and Dwell called it “astoundingly beautiful work on a subject that rarely gets the attention.” Trained as an architect, Payne is a graduate of Columbia University and the University of Pennsylvania.

Anna Schuleit’s early, large-scale installation projects revolved around psychiatric institutions: “Habeas Corpus” used the hallways and rooms of the abandoned Northampton State Hospital like the insides of an instrument for a performance of J.S. Bach’s Magnificat. “Bloom” consisted of 28,000 potted, blooming flowers throughout four floors of the at the Massachusetts Mental Health Center. Art Forum recently named “Bloom” one of the 10 outstanding art works in history. A 2006 MacArthur Fellow, Schuleit was trained at the Rhode Island School of Design.

(Elegies for Our Lost Asylums, September 29, at 8 p.m., at Tishman Auditorium, The New School, 55 West 13th Street, New York. Free; no tickets or reservations require)

The serie continues on October 20, with filmmaker Jeff Feuerzeig, who will screen his award-winning film, The Devil and Daniel Johnston.  Then, on Monday, November 22, Arts in Mind will feature acclaimed memoirist and poet Mary Karr.

For additional informations, click here.

New exhibition – “Forget me not”. Insights into asylum life around 1900

“Dr. Printzhorn, this is how it looks inside me”: For the first time the Prinzhorn Collection presents a major exhibition of testimonies from its historical collection, which reflect everyday life in psychiatric institutions.More than 120 exhibits, including paintings, drawings, collages, textile works and letters, offer a touching insight into the life of patients and at the same time present a wide cross section of the collection. Works by about 60 men and women are shown, from about 30 different institutions in the period from 1895 to 1925. We show not only famous “classics”, but also many pieces which have never been exhibited before. Madhouses, sick people’s cells, dormitories and dining rooms are documented, fellow patients and nursing staff are portrayed; an “order” is created for the “madhouse”. “May I have a piece of cake?” blossoms in dark violet; wanderlust is condensed into poetry: “Do you know the country of Orplid?” Irony and mockery are also coping strategies in “Narrenschindenau” (“Mistreat-Fool-Town”); evidenced by many caricatures, such as “Dr. Tränenausbruch” (“Dr. Burst-Into-Tears”). Nevertheless, the psychiatrist remains a “doctor and master”, as he is called in the countless letters – sincerely begging, or menacingly demanding – addressed to him asking for release after years, even decades of internment. The heartfelt, ever recurring wish not to fall into oblivion is the red thread running through the exhibition: “Vergissmeinnicht”, “Forget-me-not”; embroidered on a handkerchief, formulated as a poem, written in letters or painted as a bouquet.

For more information, click here.

New Exhibition: “The Weighty Body – Fat or Thin, Vanity or Insanity”

From October 8, 2010 till May 8, 2011 the Dr Guislain Museum in Ghent (Belgium) presents the exhibition ‘The weighty body’. It shows the fascinating ways in which humans have been dealing with their own bodily appearance. The central theme is a history of fasting. Why do people abstain from food? Are their motives personal or aesthetic, religious or financial? When do we speak of a deranged relation to one’s own body? The exhibition is centered around four major themes: (1) the elevated body or fasting and religion; (2) the body in politics and ideology; (3) body aesthetics and eating disorders; (4) the future of the body and medical technology. The accompanying catalogue (in three languages: Dutch, French & English) is lavishly illustrated. More information, click here.

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