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Jonathan M. Metzl: In Medical Records, a Story of the Racialization of Schizophrenia

Today's post is an excerpt from The Protest Psychosis: How Schizophrenia Became a Black Disease by Jonathan M. Metzl. Metzl is associate professor of psychiatry and women's studies and director of the Culture, Health, and Medicine Program at the University of Michigan. A 2008 Guggenheim Fellowship recipient, Metzl has written extensively for medical, psychiatry, and popular publications. His books include Prozac on the Couch and Difference and Identity in Medicine

Book cover for The Protest Psychosis Reading the medical charts of the patients of Ionia State Hospital for the Criminally Insane, I felt a mixture of responsibility and deep sadness. For better and largely for worse, the Ionia charts documented the lives of the marginalized and the forgotten in novel-like detail, and in ways that made the medical records of today seem impersonal and flat. This was because the charts recorded people in two conflicting ways: in their roles as patients and convicts, as defined by interactions with the state hospital complex and the courts, and in their roles as sons, daughters, fathers, husbands, wives, or loners, as defined by letters, cards, and other texts. The charts also documented in minute detail the tragedy of what it meant to be warehoused in a state asylum at midcentury -- and in particular, in an asylum where short sentences devolved into lifelong incarceration. A number of charts contained yearly notes from patients to their doctors voicing such sentiments as "Doc, I really think I am cured," or "Dear Doctor, I believe I am ready to go home," or "You have no right to keep me here after my sentence is over." These letters stacked thirty deep in some charts, signifying years of pleading and longing and anger, together with thirty years' of responses from clinicians urging, "You are almost there" or "Perhaps next year." Invariably, the last note in each stack was a death certificate from the Ionia coroner.

I visited the archive regularly over the next four years. With the help of my research assistant, I analyzed and catalogued hospital administrative records and the charts of nearly six hundred randomly selected patients admitted to the hospital between the late 1920s and the early 1970s, under the agreement that I significantly alter all personal identifying information about patients, as I have done in the case descriptions that appear in this book. Names, dates, and places have been changed, and vignettes represent condensed and extrapolated aggregates drawn from the rich case materials. All doctor-patient dialogue and text in quotation marks is reproduced verbatim. I also visited Ionia on numerous occasions and conducted a series of oral histories with surviving members of the hospital staff, though, perhaps tellingly, I located no surviving patients despite numerous attempts.

What stories boxes tell. Ionia was its own planet, walled off, orbiting, a place where real people worked and lived and died. Then came a series of public scandals, the advent of psychopharmaceuticals, and changes in legal systems and penal codes. Decreased public funding followed, along with encroachment by regional forensic centers. Finally, the transformation. The boxes were but light-years of this implosion, vapor trails, found poems, measurable heat. Disembodied voices that told silent stories of what it meant to be incarcerated, or neglected, or entrenched, or immured.

Deinstitutionalization, that failed social experiment of the 1960s and 1970s, seemed a viable explanation for Ionia's stunning demise. Deinstitutionalization combined economic considerations with reactions to appalling conditions in mental asylums to push for the liberation of persons warehoused in state psychiatric hospitals. In the United States, the movement's crowning achievement was the Community Mental Health Act of 1963, which undercut large mental institutions by transferring funding to nonresidential community mental-health centers. According to the psychiatric epidemiologist Richard Lamb, the result was "mass exodus of mentally ill persons from living in hospitals to living in the community . . . in 1955, when numbers of patients in state hospitals reached their highest point, 559,000 persons were institutionalized in state mental hospitals out of a total population of 165 million; in 1998, there were 57,151 for a population of more than 275 million."

Ionia suffered a similar fate. Administrators worried that the Community Mental Health Act provided cover for the state legislature to cut funding for hospital operations. Concern turned to near panic in the aftermath of local amendments such as Michigan House bills 3344, 3342, and 3343, which effectively reclassified many criminally insane patients as simply insane. Key referral sources disappeared overnight, and long-incarcerated patients walked free. By the mid-1970s, as longtime Ionia ward attendant Louise Cook recalls, patients could be seen "shuffling down city streets, talking to themselves." "Some patients couldn't make it on their own," added another former employee, Naomi Lutz. "So they would on occasion walk back to the hospital and ask to be readmitted. But we couldn't keep them, of course." Another former attendant, who asked that his name not be used, remembers thinking that deinstitutionalization was a conspiracy: "What better way for the Russians to get even with us than to let all of the mental patients loose!"

However, the more I read, the more it became clear to me that Ionia did not let all of the patients loose, and that deinstitutionalization did not tell the whole, fateful tale of the hospital and its inhabitants. If deinstitutionalization told the whole narrative, then why did so many charts from the 1960s and 1970s describe unruly male patients admitted and contained well after the process of hospital closure had begun? Like Cecil Peterson, these men were blue-collar workers from Detroit. Many were sent to Ionia after convictions for crimes that ranged from homicide to armed robbery to property destruction during periods of civil unrest, such as the Detroit riots of 1968. Some of the men entered the system half-crazed already. "Family reports long history of hearing voices," or "suspicious that neighbors poisoned his food." Others, such as Mr. Peterson, developed their symptoms only after incarceration, and likely abuse, in state prisons. "Nine months in solitary . . . Now markedly combative . . . appears delusional." In both instances, ward notes emphasized how hallucinations and delusions rendered these men as threats not only to other patients, but to the authority represented by clinicians, ward attendants, and society itself. "Paranoid against his doctors and the police." Or, "would be a danger to society were he not in an institution."

Ionia held these men using little-known loopholes in deinstitutionalization amendments that stipulated that the hospital would continue to receive or contain patients deemed too violent for state correctional institutions, or who posed "dangerousness to the community" even after most other patients were set free. The word negro appeared on the upper right corner of the face page in eight out of every ten of these charts. And schizophrenia, paranoid type was overwhelmingly the most common diagnosis applied to these men, these institutionalized black bodies that deinstitutionalization left behind.

How did a group of African American men from Detroit become deinstitutionalization's invisible, inevitable undertow? The most obvious answers turned out to be incomplete. Race-based misdiagnosis, the racist intentions of doctors, and even the actions or symptoms of the men themselves did not fully explain why Ionia incarcerated these men for periods well beyond their original sentences. Rather, the men's confinement resulted from a longer process of racialization in which schizophrenia morphed from an illness of pastoral, feminine neurosis into one of urban, male psychosis, not just within American society, but within the asylum's increasingly sturdy walls.

Scholars have long argued that medical and governmental institutions code threats to authority as mental illnesses during moments of political turmoil. Much of the best-known literature on the subject comes from outside the United States. International human rights activists such as Walter Reich have long chronicled the ways in which Soviet psychiatrists in so called Psikhushka hospitals diagnosed political dissidents with schizophrenia. Meanwhile, Michel Foucault often cited French hospitals as examples to support his belief that the discourses of the human sciences produce and discipline deviant subjects in the larger project of maintaining particular power hierarchies. Foucault also importantly developed a theory of "state racism," whereby governments use emancipatory discourses of what he called "race struggle" as excuses for the further oppression of minority groups. Meanwhile, the Martinique-born psychiatrist Frantz Fanon called on his experiences in Algeria to describe a North African syndrome in which political and medical subjugation literally created psychiatric symptoms in colonized subjects. Fanon's important schema, discussed at length below, focused on the ways in which racist social structures reproduce themselves not only in political or economic institutions, but also in the "damaged" psyches of people it needs to control.

The more I learned about the men at Ionia, the more I came to believe that, far from the national glare, a similar process may have taken place in the United States. Ionia's schizophrenic patients in the 1930s, 1940s, and 1950s often appeared as if downtrodden Olivia de Havillands, lower-middle-class women and men down on their luck. To be sure, the hospital did admit very small numbers of African American women—on average, only three admissions per year. But, the hospital classified the majority of women as "U.S.- White," which was not surprising given the demographics of rural Michigan and the anything-but-desegregated admissions policies of this nominally desegregated hospital. The next section describes one such case, a woman I have called Alice Wilson who was admitted to Ionia in the 1940s after creating a public disturbance while shopping at a general store.

Yet 1960s-era changes in hospital demographics, mental-health policies, popular attitudes, national events, and a host of other variables altered the meaning of schizophrenia in profoundly political ways. Parens patriae gave way to police patriae. Increasingly biological and chemical definitions of mental illness made it ever more difficult for doctors and patients to recognize how clinical issues mirrored structural ones. The state classified fewer and fewer women as criminally insane—and then shut the women's ward completely. Civil unrest filled the airwaves and the streets. Detroit burned. Ionia transformed. Only at the end of this diagnostic, cultural, and, ultimately, institutional shift were unruly black men from Detroit viewed as suffering from a disease called schizophrenia. And only then did the Michigan mental-health system treat these men, and retain them, as such.

When read through the lens of the racial politics of the 1960s, the archived charts suggested that, at Ionia at least, deinstitutionalization was far from a monolithic process. Its oratory demanded freedom for mental patients. But the revolution's on-the-ground practice took intimate account of race as well. In this sense, deinstitutionalization did not simply dictate which patients the state set free; it also decided which patients the state held onto.

Ultimately, the charts served as object lessons in the story I now turn to tell: how the rhetorics of liberation, from deinstitutionalization to civil rights, also produce anything-but-emancipatory anxieties about social change. And, how, as a result of these anxieties, a hospital for insane criminals became something else instead.

Related reading:

Who Are You Calling Crazy? by Melissa Harris-Lacewell at the Nation

Black Men More Likely to Be Diagnosed with Schizophrenia at Psych Central

Schizophrenia as Political Weapon at The Root