Jonathan M. Metzl, MD, PhD, is a psychiatrist who also has a Ph.D. in American Studies. He is Associate Professor of Psychiatry and Women's Studies and Director of Program in Culture, Health, and Medicine at the University of Michigan. In this capacity he works as a Senior Attending Physician in the adult psychiatric clinics and teaches courses in the areas of history of psychiatry, gender, and health at the undergraduate and graduate levels. He is the author of "Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs" (Duke University Press, 2003), and of "The Protest Psychosis: How Schizophrenia Became a Black Disease" (Beacon Press, 2010).
Jonathan Metzl: Jonathan Metzl. I’m Associate Professor of Psychiatry and Women’s Studies and director of the program in culture, health, and medicine at the University of Michigan.
Question: What does your daily work consist of?
Jonathan Metzl: Absolutely, yeah. So basically I have a split appointment at the University of Michigan. The majority of my time is spent teaching graduate and undergraduate courses on the history of psychiatry, the history of medicine, and also on gender and race politics in the United States. I also work as a psychiatrist at the university, so I also am an attending psychiatrist in the outpatient psychiatry clinic and I work in the psychiatric emergency room and other treatment sites.
Question: What is schizophrenia, and what is schizophrenia not?
Jonathan Metzl: So in terms of present day psychiatry, I mean, as you mentioned there have been changes with every new version of the DSM, the Diagnostic and Statistical Manual that have come out, that have sharpened our understanding of what schizophrenia is, and so in the present day we think of schizophrenia as an illness that the main symptoms are delusions, hallucinations, most hearing voices, sometimes seeing things, kind of losing touch with reality, also paranoia, feeling like people are out to get you and social withdrawal, what are called negative symptoms, so cognitive withdrawal, social withdrawal, so it’s a very debilitating, very serious mental illness, but as you mentioned this definition has changed over time and it’s also changed in relation to changing popular perceptions about how people with schizophrenia act.
Question: How was schizophrenia originally defined, and how has this definition changed over time?
Jonathan Metzl: Sure, so in my book that’s in part the story I tell, is how changing psychiatric definitions of schizophrenia and changing American cultural definitions of schizophrenia really have morphed in relation to each other over time and particularly in relation to histories about race in the United States, so one of the central narratives of the book is that in particularly the early 1920s, 1930s, 1940s when the idea of schizophrenia itself was first coming to the United States from Europe there was a general assumption that persons who suffered from schizophrenia were either shy or calm or they were geniuses. It was often represented as an illness that afflicted white novelists or poets and as I say, these were very often in popular and psychiatric representation assumed to be white people. Now this was a... you know a kind of gross generalization, but in part what was happening was that the illness itself was defined almost as a personality disorder, like a split personality, so it was taken up by psychoanalysts, used in psychoanalytic sessions and popular representation really picked that up. Two instances from this time period that I think are very important, one is a film that came out in 1948 called The Snake Pit, which was an Olivia de Havilland movie made from a book several years earlier of the same name and it really showed schizophrenia as being an illness that afflicted in particular white middle class women. Also when early versions of the Diagnostic Manual came out in the early 1950s it really was… It was called at that time schizophrenic reaction, and it was assumed to be mostly a personality condition.
All of a sudden in the 1960s, American culture, newspapers, magazines, movies start to represent angry African-American men as in part being inflicted with a new form of this particular illness, so in the book I show some drug ads, for example, that actually show pictures of urban riots and race riots in the streets, and talk about how really the illness… assumptions about the illness change and the other key thing that happens in the 1960s is that the official psychiatric definition changes. All of a sudden in 1968, the second version of the Diagnostic Manual comes out and there is new language that says aggression, hostility, projection. This is all added to the definition of paranoid schizophrenia, and what I show is that those terms were preferentially used not only to talk about these new kinds of patients, African-American men, but also to change our ideas about how violent people with schizophrenia are, how hostile they were, how they might act, which led to a lot of fear.
Question: Was the racialization of schizophrenia conscious or unconscious?
Jonathan Metzl: Even the people who we might think of as being problematic in a way, doctors who were at that point overdiagnosing schizophrenia in African-American men, I found so… I mean the drug ads I would say are, and I invite people to look at the images. They’re in the book. They’re… I mean I don’t know what the people were thinking at the time, but they were just problematically racist and I think it’s hard not to look at those ads and see anything else, but in general I think that many of the doctors in the sources that I look at were actually trying to help people. They were using the new state-of-the-art diagnostic criteria that were coming from their profession, and I found relatively few examples of people actually trying to hurt people. What they were saying was is, oh, here is a new definition of illness that we can apply to people and I think a lot of the changes were happening as you suggest, at a much bigger level, institutional levels, structural levels, the level of the kind of cultural unconscious in a way that was shifting how we thought about these people. So you know a few examples from the hospital I looked at. I tell the story of different groups of patients through the book project and some of the key people I talk about were African-American men and let me just back up first and say that this was a hospital, the Ionia State Hospital for the Criminally Insane that is or was about three hours north of Detroit and it’s kind of a central part of the story I tell because in the 1920, ‘30s, ‘40s, ‘50s the census listed the majority of patients in the hospital as being members of a category called US whites and most of the patients were from the rural Midwest. About 30% of the hospital were women and there were assumptions that these patients were… especially patients with schizophrenia were not particularly violent, so they would take these people out on fieldtrips, bring them to the State Fare, have them go and interact with the community.
All of a sudden, in the 1950s and really the 1960s, you see increasing numbers of African-American men brought to the hospital from Detroit for various reasons. Some had committed crimes, some had participated in civil rights protests, some had been participants in urban riots at the time. They all passed through various forms of the penal system and ended up diagnosed with schizophrenia and locked in the psychiatric wards and so it was a very complicated question for me. How did these men end up diagnosed with schizophrenia? Was it because of some inherent illness? Was it because of their participation in antigovernment protests? Was it because they had been abused in the prison system? I found evidence for all three of those narratives, but what was interesting was the early people, the women who had been diagnoses with schizophrenia were all re-diagnosed as suffering from depression or bipolar disorder and a lot of them were let go actually in the deinstitutionalization movement, but many of the men who had been part of these protests actually ended up staying in even as the hospital itself changed into something where security was much more of an issue and you see the hospital itself develop more and more fences, barbed wire, moats and actually at the end of the story I tell, the hospital itself becomes a prison in 1977 and functioned for about the next three decades as a medium security prison. So it really was this transformation not just in assumptions about schizophrenia, but about how we think about people with schizophrenia as being initially kind of docile and harmless to being threats, and in fact threats that needed to be in prisons in addition to psychiatric hospitals.
Question: How has the racialization of schizophrenia impacted African-American culture?
Jonathan Metzl: Basically the central argument of the book is that there was a transformation in popular and medical and psychiatric understandings of schizophrenia that happened in the 1960s in relation to certain responses, different kinds of responses to the civil rights era and to the tensions of the civil rights movement at the time, and I show pretty directly how civil rights politics, civil rights anxieties, other kinds of things really shaped our understanding of insanity in this country, and one part of that narrative is that, as I was mentioning before, we developed at that time a belief that schizophrenia was an illness that was increasingly marked by anger, hostility, projection and even though that is not part of the diagnosis anymore you see the origin in the 1960s of a set of stigmatizations of people with schizophrenia in particular as being violent that rose throughout the latter half of the 20th century even after they were associated with race. All of a sudden this… Initially this was a category that was applied to these angry, protesting African-American men, but you see a broadening of this stigma to the point where it came to apply to all persons who suffered from schizophrenia and there are great research studies that actually come from Phelan and Link, two sociologists here at Columbia that show that even though Americans have actually grown more accepting of particular mental illnesses, stigma against depression, obsessive-compulsive disorder, anxiety, have all gone down over the last 50 years. Stigma against schizophrenia, particularly as being violent, has risen over the same time period, and I think this history tells us why. So one aftereffect of this period is stigma against schizophrenia as being violent. A second thing we see in the aftermath of this history is a literature that is called the misdiagnosis or overdiagnosis of schizophrenia in minority populations, particularly black men.
A third area, which I can talk about in a bit if you wish, is the criminalization of mental illness and this assumption that people with schizophrenia are threats to the state in a certain kind of way. But there is a flip side to the story as well, which is that schizophrenia was also a metaphor, a term, a linguistic usage that was taken up within civil rights discourse itself. I have a few chapters where I talk about how schizophrenia became a term that Martin Luther King used in seven or eight of his main sermons and in a bunch of his writings and for King schizophrenia was an illness that… It actually wasn’t an illness. What he said was schizophrenia literally means split mind and he said there is a split in our minds between good and evil, dark and light and what we need to do is choose the path of nonviolent resistance. Schizophrenia was also a term that was taken up by leaders of the Nation of Islam, the Black Power movement, Malcolm X was himself misdiagnosed with schizophrenia in a CIA file. I talk about that in the book. Many of the leaders used schizophrenia, but what they said is it’s not an illness of the black mind. Instead, schizophrenia is a response to the illness of white racism that basically this is a justifiable means of fighting back against white society and it’s interesting for me. What I do is track through that particular usage and show how that didn’t disappear and part of the way I get to that is to look at present day uses of mental illness terms in rap and hip-hop and popular cultural music. I do a kind of mini research project where I look at lyrics databases and first what I do is look for terms like “depression” or “depressed” across all American popular music, and what you find is that terms like depression and depressed show up in the lyrics of people like America, Styx, Celine Dion, Joanie Mitchell, the Eagles, you know, kind of what you might call white crooning in a certain kind of way - I hate to over generalize. But it’s very often assumed to be a particular mood disorder, but if you go into the same databases and you type the word “schizophrenic,” “schizophrenia” or “schizophrenic,” as I talk about in the book, and I list references to over 200 rap or hip-hop artists, the artists are actually calling themselves schizophrenic. Tupac, Isham, other artists, and basically what they say is, “Yeah, I’m schizophrenic and I’m violent and I’m hostile and I’m a threat to you or to other rappers or to the police or to the state and you better get out of my way.” It’s really interesting to say, why would this mental illness term show up in hip-hop, right? And on one hand, which I think would be wrong, is to say well they’re taking psychiatric usage in a way, and saying I’m just crazy or something like that, which is in part true, but for me it’s actually saying this history, this usage, is actually coming from an earlier tradition. It’s coming right out of the usage in Black Power in the 1960s, basically saying hostility is a response to structural violence and I’m going to assume this identity as a way of fighting back and so it’s interesting that it remains a protest identity in this particular form.
Question: How did mental illness become increasingly criminalized in America?
Jonathan Metzl: Really one of the things I really try to do very consciously in the book is to track a particular evolution of that process, and part of what I show is that even though we had all these asylums in the 1930s and ‘40s and ‘50s where we locked away all of these people there was this… and often for long periods of time, but not always. There was this assumption that we were kind of treating people in a certain kind of way, that there was a possible recuperation or cure. Obviously didn’t happen for a lot of people, but you know there was an investment. I mean people were being locked away, but they were also seen as responsibilities, particularly in schizophrenia, of the state and part of what happens with this definitional and racial change in the way schizophrenia is understood in the ‘60s is a feeling that these people aren’t just docile dependants of the state. They’re also threats to the state. Particularly with schizophrenia you see a lot of concern that these people could escape and kill people, or they could threaten our political order, and particularly in the 1960s when schizophrenia becomes linked to civil rights protest. It’s also schizophrenia could bring down the state in a very… You know this has happened in other countries, so it’s not surprising, but we don’t often think about that in the United States, but I think part of why schizophrenia got linked to civil rights protest in the ‘60s was because mainstream society was coding threats against the smooth running of the state as insanity and treating it as such, and so as that happens you see the evolution of a process in which people with schizophrenia are increasingly feared and our hospitals, particularly the kind of hospital that I look at in the book become to look more and more like prisons, to the point where many of them including the one I talk about actually become prisons.
And that is something that didn’t just happen near Detroit where I look, but across the country. According to Human Rights Watch for example in the present day if you are a person diagnosed with schizophrenia and you are in a state institution you’re chances are exponentially greater that that institution is going to be prison rather than a hospital. Bernard Harcourt, a law professor at the University of Chicago, talks about the transformation from a hospital-based institution to a prison-based institution, and it’s something that happened across the country and that happened obviously for many reasons, but part of it is this transformation and in which prisons became our de facto mental hospitals, and we saw mental illness as in some way threatening not just to the people who suffered from it, but also us, mainstream society.
Question: What contemporary psychiatric diagnoses do you believe are based on faddish social thinking?
Jonathan Metzl: Well you know, again, I’m a practicing psychiatrist and I think that I really believe in the advances of psychiatry. Our diagnoses are more precise. They get more precise with every volume of the Diagnostic Manual. Our treatments slowly get better over time and I’m not averse to saying that there are biological basis to mental illness. I’m part of a department that does a lot of fantastic research in brain imaging, scans, other kinds of genetic research that really looks at mental illness seemingly below the level of culture, context, race, ethnicity, at the level of brain structures that are seemingly the same in all people, and at the same time I feel like there is a false divide, almost like you have to vote, is an illness biological or is it social or socially constructed, and I don’t like that divide very much because I think that all definitions of illness and maybe particularly all definitions of psychiatric illness are always both. It doesn’t have to be one or the other. Mental illness is a real thing. It has real material consequences for people who suffer from it and at the time even the most biological finding reflects social context in very important ways, and so I think psychiatry is better off looking both at biology and at social context and really trying to think of the relationship between these and I think doctors and patients are better off that way. We certainly know that depression is an illness. All you have to do is watch an antidepressant advertisement on television right now and think about why might it be that a person might see an ad like that. What are the forces that are leading them to go in and ask a doctor? In part it might be that that ad speaks to some symptoms they’re having that are chemical symptoms, but many of these ads play off of familiar cultural stereotypes about gender or parenting or social class, other kinds of things and so I think doctors need to be aware of both that. Depression as one example is an illness that has a chemical basis, but also is deeply embedded in cultural norms about gender, social class, race, so that would be one example. There is great work that has been done now on bipolar disorder by Emily Martin here at NYU and looking at the kind of cultural basis of bipolar disorder. Obsessive-compulsive disorder after the show Monk, for instance, is something that there is a lot of popular conversation about and so I think again it’s true for all illness, but it’s certainly true for psychiatric illness that these illnesses often reflect cultural norms in addition to biological realities, and really we have to be fluent in both.
Question: Will mental disorders ever be defined as precisely and universally as bodily disorders?
Jonathan Metzl: Right, well again, I think that we’re making a mistake if we don’t see that there is a cultural basis to many illnesses, not just psychiatric ones. Breast cancer would be one prevalent example right now, different kind of cultures surrounding it. If you don’t understand the cultural meaning of an illness like that you’re going to miss the boat even if you’re a great scientist. So I don’t think it’s the case that it’s just psychiatric disorders, but we know from history that when we get the ultimate, you know, cure for a particular illness or nail it down it stops being a psychiatric illness and then it’s taken up by internal medicine or, you know, we know, oh, it was just and iron imbalance or it was a vitamin deficiency or something like that, but in a way it’s taken from psychiatry and taken to medicine. But I think that you know if you look at diagnostic rates and treatment rates in psychiatric disorders it’s - even with all the controversy about SSRIs right now the improvement rates are reasonably good compared to other medical specialties, and so I think it’s always going to be a negotiation about what is the best way to understand psychiatric illness, but of course the flip side of that is that there is this aura of it’s something we don’t know in a certain kind of way, and so psychiatry is always kind of fighting against that, and probably that’s why we had a move toward saying things are solely biological in a certain kind of way is to, you know, rightly move toward a more scientific basis.
Question: How will more advanced neuroscience and neurological treatments change psychiatry?
Jonathan Metzl: Terrific. Well I mean it’s, there are really exciting things happening in genetic and neurobiology right now, and really looking at the ways in which different not just illnesses, but social conditions and social pressures can actually lead to actual brain changes. You know there was a lot of promise in the development of pharmaceuticals, particularly with the advent of a newer generation of antipsychotics and antidepressants, and we know from history that there is a kind of natural trajectory of the way that these medications come out and are accepted. So initially we say these are cures for everything under the sun and there is this dramatic rise and then we say wait a minute, these don’t work for anything, which I think is happening with the SSRI antidepressants right now, and then we kind of figure out a moderated use of, well, they’re good for some conditions and not for others. And so again as I say, I think that there is a give and take that is part of the process and part of it is based in science, but I also think, you know, the 1990s were often called the decade of the brain in psychiatry where we didn’t need to worry about Freud or about gender or psychoanalysis, context. All these things were in certain ways kind of pitched out the window because we were going to get the answer to everything from brain scans. And I think psychiatry itself has come to, in a way like medications, a more moderated understanding of the brain itself is very important, but you don’t really know anything about the brain unless you know about social context, expectations, stigmas, other kinds of things, and so hopefully these findings will continue to be understood in social context.
Recorded on January 29, 2010
Interviewed by Austin Allen