The Dark Past of Diagnoses: Racism in the Origins of American Psychiatry

Deeksha Puri

When one imagines mental healthcare spaces, they often think of them as far removed from deeply-entrenched socio-political inequities. This individuation of mental healthcare practice forgets that this space does not exist in a vacuum and can often replicate systemic injustices. Experiences seemingly inherent to mental healthcare (like access) can become privileges in themselves—with the likelihood of obtaining a diagnosis 73% lower in African-American individuals as opposed to their white counterparts (Lipson et al., 2018). Engaging with mental health discourse, thus also prompts questions of equitable accessibility. Using a historical approach, this blog aims to articulate how the origins of clinical psychiatry in the United States have contributed towards exacerbating systemic prejudice against Black, Indigenous and People of Colour (BIPOC) communities. To do so, it will majorly focus on diagnostic developments in American psychiatry during the 19th-20th century period and their perpetuation of racial discrimination against African-American individuals.

Following this, it becomes important to establish that notions of ‘normal’ and ‘abnormal’ are dependent on pre-existing socio-cultural norms. The influence of these norms underscores

the development of various conceptions of psychopathology; the idea of ‘abnormality’ itself considerably changing over decades (Hooley et al., 2021). While ‘abnormality’ as a concept is ever-changing, its stigmatization has seemingly remained relatively consistent. One example of such stigmatization was evident in the 19th century—with mental health professionals termed as “alienists” who treated the “alienated” (those affected by mental illnesses) (Hooley et al., 2021). Thus, this quite literally, presents individuals with mental disorders as an alien ‘other’, subject to exclusion and ostracization. Additionally, when social stratification stands on the marginalization of certain identities, conceptions of ‘abnormality’ within psychopathology can serve as tools to actively ‘other’ marginalized individuals, exacerbating their marginalization further. 

History is replete with such ‘othering’ conceptualizations of abnormality, reflected in the diagnoses of African-American individuals in clinical psychiatry during the 19th century, many of which were egregiously unscientific. Samuel Cartwright, a prominent physician in 1850s America, described a disorder called “drapetomania”, which he claimed was a mental illness consisting of “sulky and dissatisfied behaviours” causing black slaves to run away from captivity (Lowe, 2006; Perzichilli, 2020). He argued, using The Bible, that slaves needed to be kept in a “submissive” state, and should be “treated like children” to prevent them from running away (Perzichilli, 2020). Such claims not only perpetuated the oppression of people of colour but also justified it. In using baseless theological arguments rather than empirical evidence, Cartwright infantilized and ‘othered’ African–American individuals through pseudoscientific ‘diagnoses’ that underscored racial discrimination. He coined another diagnosis called “dysaethesia aethiopica”, referring to a pattern of “mischief” that appeared as “intentional” concerning work habits among slaves (Lowe, 2006). 

Furthermore, Benjamin Rush, who is considered the father of American psychiatry, despite being an abolitionist, believed that he could “cure” African slaves of their skin colour, which he postulated was due to “sickness” caused by imbalances in bodily humours, the treatment for which was becoming white (Driggers, 2019). By presupposing that being black was to be ‘cured’, Rush actively contributed towards ‘othering’ people of colour. Similar to Cartwright, he utilized medicalized, yet unscientific terminology to reinforce pre-existing racial hierarchies. Cartwright and Rush’s ‘diagnostic’ postulations left a lasting imprint on clinical psychiatry and its indoctrination and endorsement of racial prejudice. “Drapetomania” was not removed from the Practical Medical Dictionary until 1914 (Perzichilli, 2021), and Rush’s medicalized terminology was used to rationalize the ill-treatment of slaves (Gordon-Achebe et al., 2019). 

In many ways, the medicalized terminology used by Cartwright and Rush to justify racial bigotry laid the bedrock for the ill-treatment of people of colour in mental-healthcare setups. Lowe (2006), in his review of 19th-century mental healthcare for African-Americans, maintains how the etiology of mental illness in African-American populations was vastly different from the etiology of white populations. According to Lowe, the pathology of the former was rooted in views of “biological defect, social inferiority, and political subjugation” (Lowe, 2006). This is elucidated by the implications undergirding Cartwright and Rush’s postulations— either infantilizing or demonizing people of colour, while presenting them as inferior. 

However, this etiological discrimination didn’t remain a relic of the past; continuing to pervade the field of psychiatry even in the 20th century. In his book Protest Psychosis: How Schizophrenia Became a Black Disease, Jonathan M. Metzl outlines how in the wake of the Civil Rights Movement in the 1960s, schizophrenia took on the name “protest psychosis”, to describe black men who were “hostile and aggressive”, and prescribed to “anti-whiteness”, by

listening to the Black Panthers, and Malcolm X (Metzl, 2010). He further presents that after the 1960s urban unrest, white clinicians started to primarily associate schizophrenia with “angry black masculinity” (Metzl, 2010). Even leading research articles started to attribute ‘black’ forms of the illness to “volatility and aggression” in unfounded ways (Metzl, 2010). This illustrates how the stereotype of the ‘angry black man’ was perpetuated by diagnostic criteria and later used to disproportionately disenfranchise and institutionalize African-American individuals. Metzl’s example articulates how even resistance to oppression came to be unscientifically pathologized, suggesting the confluence of marginalization and psychiatry to cement racial differences further. Unfortunately, remnants of such stereotypical and unscientific notions pervading diagnostic criteria continue to follow in the 21st century. Despite negligible genetic evidence supporting a true increase in the prevalence of schizophrenia amongst African-American individuals, they are five times more prone to be diagnosed with it as opposed to Euro-American individuals (Schwartz & Blankenship, 2014; Grinker, 2020). Reiterating Lowe’s (2006) perspective, this elucidates how disorders become amenable to discriminatory etiologies based on race. 

Considering the emergence of prejudicial factors in diagnostic criteria, therefore, becomes essential in understanding why there exist glaring disparities in mental healthcare across races, and how the malleability of the notion of abnormality to these same factors contributes to marginalization. The historical maltreatment of people of colour by American psychiatry—deeming them as “inferior” in the case of Cartwright and Rush and subjecting them to disproportionately inaccurate diagnoses as illustrated by Metzl, helps better understand the apprehensions amongst people of colour in approaching mental healthcare facilities. Furthermore, a greater understanding of this history and the trauma associated with it can allow psychiatrists to cultivate greater cross-cultural sensitivity. Henceforth, the politics of race and mental illness cannot, and should not be separated from our envisioning of mental healthcare. 

References

1. Driggers, E.A. (2019). “The Chemistry of Blackness: Benjamin Rush, Thomas Jefferson, Everard Home, and the Project of Defining Blackness through Chemical Explanations”. Critical Philosophy of Race, Vol. 7(2), 372-391. doi: https://doi.org/10.5325/critphilrace.7.2.0372. 

2. Gordon-Achebe, K., Hairston, D.R., Miller, S., Legha, R. & Starks, S. (2019). Origins of Racism in American Medicine and Psychiatry. In M.M Medlock, D. Shtasel, N.H.T. Trinh & D.R. Williams (Eds.), Racism and Psychiatry: Contemporary Issues and Interventions (pp. 3-19). Springer Nature. 

3. Grinker, R.R. (2020, August 18). The Racist Origins of the Modern Concept of "Schizophrenia". Psychology Today. https://www.psychologytoday.com/us/blog/nobodys-normal/202008/the-racist-origins-the-modern-concept-schizophrenia

4. Hooley, J.M., Nock, M.K. & Butcher, J.N. (2021). Abnormal Psychology (18th ed.). Pearson Publishers. 

5. Lipson, S.K., Kern, A., Eisenberg, D., Breland-Noble, A.M. (2018). Mental Health Disparities Among College Students of Color. Journal of Adolescent Health, Vol. 63(3), 348-356. doi: https://doi.org/10.1016/j.jadohealth.2018.04.014. 

6. Lowe, T.B. (2006). “Nineteenth-Century Review of Mental Health Care for African Americans: A Legacy of Service and Policy Barriers”. Journal of Sociology and Social Welfare, Vol. 33(4), 29-50. doi: 

7. Metzl, J.M. (2010). The Protest Psychosis: How Schizophrenia Became a Black Disease. Beacon Press. 

8. Perzichilli, T. (2020, May 2). The Historical Roots of Racial Disparities in the Mental Health System. Counselling Today. https://ct.counseling.org/2020/05/the-historical-roots-of-racial-disparities-in-the-mental-health-system/

9. Schwartz, R.C. & Blankenship, D.M. (2014). “Racial Disparities In Psychotic Disorder Diagnosis: A Review Of Empirical Literature”. World Journal of Psychiatry, Vol. 4(4), 133-140. doi: 10.5498/wjp.v4.i4.133.