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Monday, April 18, 2011

Meta-review: Schizophrenia and racism

The publication of Jonathan Metzl's The Protest Psychosis: How Schizophrenia Became a Black Disease has generated a number of reviews. While all reviewers have plenty of praise for his project, there is a discussion about his main argument that the becoming of schizophrenia as a black disease is basically a matter of misdiagnosis because of the psychiatric professions' racism. Some of these reviews rubbed me the wrong way, and this blog post is my attempt in explicating my unease.

Tanya Luhrmann, anthropologists and author of a great ethnography of psychiatric institutions, argues that this argument missing a crucial point: the different rates of prevalence of schizophrenia in different ethnic groups.

If one has a dark skin, one's risk of schizophrenia increases as one's neighborhood whitens, a disturbing finding known as the "ethnic density" effect. The risk of developing schizophrenia among African Caribbeans who have migrated from Jamaica to the United Kingdom is as much as 15 times higher than that among the local whites; the effect holds true for black-skinned Surinamese who have immigrated to the Netherlands.
There is, therefore, a mixture between "being schizophrenic" and "being classified as schizophrenic" in action: Not only are members of racially disadvantaged groups more likely to be diagnosed (Metzl's position; misdiagnosis model); but members of racially disadvantaged groups are more likely to have schizophrenia (Luhrmann's model; racism as risk factor model).

These two explanations are not completely incompatible--Luhrmann clearly acknowledges that misclassification is indeed going on-- but they also don't go together easily. First, if persons from racially disadvantaged groups are indeed at higher risk of having schizophrenia, then one could argue that a higher rate of diagnosis for them just reflects this reality and there is no problem. In this sense, the coming into existence of schizophrenia as a black disorder that Metzl describes could actually be seen as an improvement. Obviously, this is not where Luhrmann and Neely Myers, who reviewed the book on Somatosphere, want to go, but I think this issue has to be addressed.

The underlying ontological and epistemological issue that would help sorting this out is that of the reality of mental illness. Luhrmann's position is based on a position that assumes that schizophrenia exists "out there," without explicating what that schizophrenia is. Is schizophrenia sufficiently defined by its behavioral symptoms listed in the DSM? Is is it an experiential category? Is it a specific kind of "physiology of despair and resilience and [...] individually shaped both genetically and epigenetically," as Neely Myers argues? Aside from this problem, in principle, there is nothing wrong with insisting on the reality of mental disorders, and Luhrmann points out that members of African Caribbean communities in London themselves "attribute their high rates of schizophrenia to the experience of living in poverty with a history of racism and slavery." Dismissing Metzl's misdiagnosis argument as that of a detached liberal academic that doesn't want to acknowledge the devastating effects of poverty and racism appears misguided, though.

Why, for example, do the African Caribbeans mentioned above think of their condition as resulting in schizophrenia and not in terms of a different diagnosis or in non-psychiatric terms? The creation of categories and that of identities go hand in hand, as Ian Hacking has so convincingly argued. Metzl's historical account of the classification of schizophrenia helps us to unravel the creation of an "ecological niche" (Hacking) that not only has allowed psychiatrists to label and institutionalize "angry black men" as schizophrenic, but also allowed disadvantaged communities to think of their social situation in terms of mental disease.[1]

My objections notwithstanding, I think Luhrmann and Myers have pointed out something important when it comes to the conclusions to be drawn from Metzl's analysis. Racism is not merely a matter of the psychiatric profession misdiagnosing certain groups of people. Living in a racist and economically unjust society clearly does something to those affected by it, and dealing only with psychiatry won't make that something go away. To think of the effects of racism primarily in psychiatric terms, however, is no solution either. I hope this debate will continue in a productive manner.

[1] I wonder if those diagnosed with schizophrenia by psychiatrists and their community share the perspective of schizophrenia as a product of racism. Emily Martin's Bipolar Expeditions is very helpful in thinking about the experience of "living under the description" of a mental disorder. 

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