A Post-Racial Public Mental Health System: If Not Now, When?

In answer to the question posed in the title to this article, probably not for a long, long time. Or perhaps more accurately, when the entire country does.

We often seem to forget that the public mental health system reflects the larger social system of which it forms part. To judge from the pronouncements that emanate from local and Federal governmental agencies, many of us, whether providers or peer/survivors, continue to define our reality and our own identities within a parochial system that seeks to avoid harsh realities. Specifically, it ignores poverty, as I’ve written in earlier articles, and makes use of euphemism to protect the sensibilities of those in the system who have power. The best example of the latter is the willingness of government agencies in New York State and elsewhere to promote discussions of “multi-culturalism”, yet no word about racism.

Now it’s hard to quarrel with multi-culturalism: no victims and no victimizers, validation of cultural self-identity and pluralism, promotion of public amity. On the other hand, when you talk about racism, there’s bound to be discord and a lot of apprehension. I was introduced to multi-cultural training in the early 1990’s by Anita Pernell Arnold, an African-American social worker, who established multi-cultural training institutes in Philadelphia and Cleveland. When I look back at those times –I was a visiting faculty member at both venues, teaching courses about Irish- and Italian-Americans, my cultural heritage – I can see more clearly now that Pernell-Arnold’s intent was to level the playing field, to demonstrate that inter-group differences were cultural rather than innate, that each hyphenated American ethnic group’s social worth was equal one to the other. Racism, which would have involved examining the social and institutional forces that drove it, was not discussed.

We didn’t think we had the language — and certainly lacked the will – to talk about it. We were still in thrall then to the rhetoric of Nixon’s “Southern Strategy”, which played on white Southerners’ resentment of black Southerners’ restored citizenship; of Reagan’s “welfare queens”, which depicted African-Americans as welfare state freeloaders; and Bush I’s “Willie Horton”, all-black-men-are- violent-criminals, video. And then we saw Rodney King – who died a few days ago, on June 17 at the age of 47 – on a home video get the hell beaten out of him by LAPD cops, renowned for their hatred of blacks and Latinos; we saw an all-white jury in Simi Valley, at the outer reaches of L.A. County, set free the four white cops charged with assaulting Mr. King; and then we saw South Central LA erupt in rage and flames, a self-destructive act and the hallmark of an oppressed, victimized people. Now those of us who needed it had the proof, on videotape, of institutionalized violence against people of color, and the pictures and their graphic portrayal of specific acts of violence gave us the words and the moral imperative to begin speaking out.

It took nearly twenty years after Rodney King’s beating, but in 2010 two landmark books were published, Michelle Alexander’s The New Jim Crow: Mass Incarceration in the Age of Colorblindness, and The Protest Psychosis: How Schizophrenia Became a Black Disease, by Jonathan Metzl. Both are “must” reading for anyone in this country concerned with social justice. Both document the purposefully discriminatory treatment meted out over the past forty years to African-American men caught up in the criminal justice and public mental health systems, two of the principal agencies of social control in our society. Metzl tracks the evolution of the application of the diagnosis of schizophrenia to African-American men in a state forensic psychiatric hospital outside of Detroit in the early 1970’s. To sum up his hypothesis, the behavior of African-American men at that time, when many were protesting their continued oppressed status despite the restoration of their civil rights, was pathologized and criminalized solely because they were African-American men. I’ll discuss Metzl’s work and its present-day implications in the latter part of this article.

Alexander’s work has garnered greater notoriety because of the forcefulness of the arguments she presents and the sheer weight and drama of her corroborating statistics. Her fundamental contention is that Jim Crow, or a racial caste system, is alive and well in 21st Century America. Her proof?
• “There are more African-American adults under correctional control today … than were enslaved in 1850 …
• As of 2004, more African American men were disenfranchised (due to felon disenfranchisement laws) than in 1870, the year the 15th Amendment was ratified, prohibiting laws that explicitly deny the right to vote on the basis of race.
• A black child born today is less likely to be raised by both parents than a black child born during slavery …
• … a large majority of African-American men in some urban areas have been labeled felons for life. (In the Chicago area, the figure is nearly 80%.) … They can be denied the right to vote, automatically excluded from juries, and legally discriminated against in employment, housing, access to education, and public benefits, much as their grandparents and great grandparents were during the Jim Crow era.”

Bureau of Justice Statistics data from yearend 2010 support Alexander:
• Black non-Hispanic males had an imprisonment rate … that was nearly 7 times higher than white non-Hispanic males …
• Black non-Hispanic females … had an imprisonment rate nearly 3 times that of white non-Hispanic females …
• An estimated 7.3% of black males ages 30-34 were in state or federal prison.

Critics have countered that African-Americans simply engage in more criminal and violent behavior. Alexander’s response? “… The main driver has been the War on Drugs. Drug offenses alone accounted for about two-thirds of the increase in the federal inmate population and more than half of the increase in the state prison population between 1985 and 2000, the period of our prison system’s most dramatic expansion.” She quotes H.R. Haldeman, White House Chief of Staff for Richard Nixon, who called for the first “war on drugs”: “[T]he whole problem is really the blacks. The key is to devise a system that recognizes this while not appearing to.” Reagan declared another war on drugs in 1982 and persuaded Congress to fund it. As per Alexander, “… The drug war was part of a grand and highly successful Republican strategy of using racially coded political appeals on issues of crime and welfare to attract poor and working class white voters who were resentful of and threatened by desegregation, busing and affirmative action …”

Too conspiratorial for you? Peter Dale Scott, social critic and author of Deep Politics and the Death of JFK (1996), has co-authored three books (1987, 1998, 2003) that detail the role of the CIA in shepherding heroin shipments from the Golden Triangle in southeast Asia (Burma, Thailand, Laos), through Marseilles (the French Connection) into the U.S. in the 1950’s, ‘60’s and ‘70’s; and in coordinating the smuggling of cocaine from Colombia through Nicaragua and into the U.S., with the proceeds from its sale funneled to Iran for guns for the anti-Sandinista contras in the 1980’s. His third book tracks the travels of raw heroin from Afghanistan to Pakistan to purchase CIA-supplied guns for the Afghani mujahedeen in the 1990’s. And where did all those drugs wind up? I can’t help remembering the scene in “The Godfather, Part II,” when Mafia overlords are discussing where to unload the heroin they’re bringing into the country? One of them says, “We’ll sell it to the schwarzes … they’re animals!” From Coppola’s and Puzo’s imaginations, of course, yet plausible. Although a good deal of heroin wound up in Harlem (c.f. Ridley Scott’s “American Gangster’) most of those drugs wound up all over the U.S., evidence, as per Dale Scott, of the widespread corruption that pervades this country.

Fortunately, there has been some pushback from advocates and affected family members. In 2010, with the passage by Congress of the Fair Sentencing Act, the Federal criminal penalties for possession of crack cocaine were reduced to a level more in line with those for powder cocaine. For the preceding quarter century, Federal prison sentences had been much more severe for possession of crack, a cheaper drug presumably favored in poor, often black communities. Scientific evidence accumulated since the 1990’s revealed that both forms of cocaine were equally addictive, removing the rationale for the sentencing disparities and making clear, as the advocates contended, the unmistakable racial bias of the original sentencing law, the inaptly named Anti-Drug Abuse law of 1986. In New York State, the harshness of the Rockefeller drug laws, passed in 1973 with stiff criminal penalties for possession of even small amounts of heroin, were somewhat mitigated in 2009 after a ten-year long campaign by inmates’ families, with sentencing judges allowed the option of sending first-time drug felons to serve their sentences in treatment rather than correctional facilities. The effects of these changes have yet to be felt, absent corroborating data, and should not expected to be dramatic. As per data preceding these changes …
• As of 2008, 22% of all African-American incarcerated in state and Federal prisons had been convicted of drug possession – as compared with 14.5% of white inmates;
• As of 2009, 12,000 or 22% of New York State’s prison population had also been convicted of drug possession, with 5,000 or 9% charged with class ‘B’ felonies or possession of one bag or one gram of heroin or cocaine.

To sum up the foregoing and Alexander’s basic thesis, the Federal government, aided and abetted by the state governments, has systematically denied the civil rights of the great majority of African-Americans, particularly African-American men, for the past one hundred and fifty years. Individuals whose rights it was the government’s responsibility to protect, have been and continue to be viewed as threats to the government and to the established social order and have been accordingly marginalized. Which is the same story that Jonathan Metzl has to tell.

He begins his story at Ionia State Hospital, a state forensic hospital outside of Detroit, in the 1960’s, a time marked by fundamental changes in psychiatry and Ionia’s patient population as well as in the larger society and those patients’ social environment. The peaceful and quiescent 1950’s gave way to civil unrest in the ‘60’s and ‘70’s. For African-Americans living in big city ghettos, the Civil Rights and Voting Rights acts failed to improve their lives, to open doors to promised opportunity, to a valued place in American society. Black nationalism and black power seemed to offer the only avenues through which urban blacks could voice their anger and disillusion and give meaning to their lives. I wrote above how the American political establishment, the Nixons and Reagans, responded to this challenge with their wars on drugs. For ordinary Americans, dissent was viewed as insane behavior, which was soon transformed into criminal behavior.

Prior to the 1960’s, patients institutionalized at Ionia and diagnosed with schizophrenia, as per DSM I criteria, were largely white women who evidenced schizophrenia’s negative symptoms – social withdrawal, anhedonia, blunted affect. With uncanny timing, the DSM II, published in 1968, introduced a biological explanation for serious mental illness and emphasized Schneiderian first rank or positive symptoms in diagnosing schizophrenia – hallucinations, delusional thinking, paranoid ideation and aggressive, hostile behavior. Black protests, particularly after Martin Luther King’s and Bobby Kennedy’s murders in 1968, grew more volatile; angry black men began to be arrested and, when their anger didn’t subside in Michigan’s jails or prisons, were transferred to Ionia’s forensic units. Where they were diagnosed with schizophrenia by psychiatrists who, confronted by angry black men, were blind to their own anxiety and to their roles as agents of institutionalized racism.

Anxiety, racism and the DSM II were not confined to Ionia; black men in mental health facilities across the country who evidenced any psychotic symptoms were invariably diagnosed with schizophrenia. For the past forty years, even with the advent of successive DSMs — III, IIIR, IV and IV TR – and presumably more sophisticated diagnostic methodology, the “over-diagnosis” of schizophrenia in African-American men has continued and gained increasing attention from mental health researchers. The Kaiser-Permanente Schizophrenia study, conducted in California from 1981 to 1997, examined 19,000 live births that took place during that time frame and determined that African-Americans, whether from poor or working or middle class families, were 3.27 times more likely than whites to one day be labeled as having schizophrenia. The researchers did conjecture that poverty and, in their words, “status discrimination such as segregated neighborhoods, differences in educational systems, opportunity structures and racist climate” might constitute “causal pathways” to schizophrenia for African-Americans, but the concluded that their data did not allow them to “examine these pathways.” The study also failed to examine clinician bias in the over-diagnosis of schizophrenia and accepted without question the construct validity of schizophrenia as an illness.

A similar study published in 1999 and conducted in Michigan and Maryland with 665 study subjects hypothesized that treatment venue might offer an explanation for over-diagnosis. Its researchers concluded that hospitalized African-Americans, whose symptoms were presumably more exacerbated, in contrast to those treated in out-patient settings, were more likely to be diagnosed with schizophrenia than white patients and less likely to be diagnosed as suffering from affective disorders. Issues of poverty, racism and clinician bias were not addressed.

NIMH’s National Comorbidity Survey, conducted almost annually since 1992, reported the statistically significant prevalence of schizophrenia among African-Americans as compared to whites. The earlier surveys i.e., those conducted since 1992 over the next several years, began to conclude that an explanation for the phenomenon of “over-diagnosis” could be found in the cultural differences between African-American patients and their treating clinicians. Specifically, they posited the existence of a culturally-rooted barrier blocking ready communication between African-American patients and their predominately white therapists: on the one hand, the reticence of African-Americans to talk about their problems to individuals outside their social milieu; and the tendency of American-Americans to view such individuals with suspicion, largely a consequence of their unhappy personal experiences with “outside” authorities; and, on the other, white therapists’ lack of knowledge about the black experience in America. The surveys’ authors, endorsed by the NIMH, invariably recommended multi-cultural training to promote mental health providers’ cultural sensitivity and cultural competence.

Only recently – the 2011 National Comorbidity Survey and William Lawson’s presentation at the 2012 APA Conference – have researchers suggested that over-diagnosis of schizophrenia in African-Americans might not be due solely to the misapplication of diagnostic criteria to a socially anomalous population but to incompetence and racial bias on the part of treating clinicians. Specifically, they cited the following:
• insufficient data gathering by clinicans;
• their assumption that first rank symptoms evidence only schizophrenia and not affective disorders as well;
• stereotypical notions of African-Americans by clinicians;
• the great social distance that exists between African-American patients and those who presume to treat them.

As I pointed out at the outset of this article, multi-cultural solutions are polite ways to avoid addressing the issue of institutionalized racism, whose existence none of these studies acknowledge.
Admitting the presence of bias in providers is a first step but doesn’t go far enough — racism is so intrinsic to the public mental health system that many of us who work in that system appear to be unmindful of it. Perhaps more importantly, none of these studies consider the possibility that schizophrenia, that most pejorative and damaging of diagnostic labels, and one whose construct validity lacks supporting data, is not a mental illness but a tool of social control. Metzl’s principal contention is that not only did schizophrenia become a black man’s disease but has been criminalized, with its primary treatment venues found in the nation’s jails and Federal and State prisons. To illustrate …
1. By the late 1970’s, at the height of deinstitutionalization, Ionia was converted from a state hospital to a state prison.
One can’t fail to wonder how many of its patients eventually shifted status from patient to prison inmate.
2. More to the point, in a 2005 survey conducted by the Bureau of Justice Statistics, a total of 1.25 million individuals incarcerated in Federal and state prisons and local jails reported some evidence of emotional disturbance, presumed indicative of mental illness: 56% of all inmates in State prisons, i.e., 700,000 individuals; 44% of all Federal prison inmates – 70,000 persons; and 64% of inmates of local jails – 480,000 persons.

In my experience, many if not most practitioners and peer/survivors in the public mental health system have some awareness of the foregoing. Most, perhaps nearly all, seem to have failed to connect the dots.

So what can practitioners and peer/survivors do to combat institutionalized racism in the public mental health system and the larger social system? For starters, they can employ what I term the “dripping on the rock” strategy in public mental health, challenging every schizophrenic diagnosis given a person of color. During the many years I directed a case management program in New York City, we would ask ourselves whether the schizophrenia diagnosis of a client new to us was “bona fide”, i.e., had sufficient supporting data, or more properly represented the sequelae of poverty, substance abuse and trauma. Which, more often than not, proved to be the case. I recommend that same approach to all practitioners and to peer/ survivors labeled with schizophrenia.

A consideration of the diagnosis would then set us off to obtain as much information about our new client as possible, avoiding easy assumptions and documenting our suppositions, by happy coincidence, a practice utilized by Dr. Lawson and his colleagues. Ultimately, the validity of the diagnosis itself must always be questioned and its utilization as a tool of social control constantly exposed. In a nutshell, don’t accept anything at face value!

Finally, remember that the public mental health system is integral to and reflective of the larger social system. Accordingly, public mental health won’t rid itself of racism or racial bias until the larger society does. I think we’re a long way off from that. In the interim, opportunities to challenge racism and oppression will present themselves and must be recognized and accepted whenever and wherever they do, whether within or outside of public mental health. I think of what’s happening here in New York City, of the silent march of several thousand persons down 5th Avenue this past June 16 to protest the NYPD’s “Stop and Frisk” policy aimed at young men of color in New York’s poorer neighborhoods. The fight to stop “Stop and Frisk” appears to have gained public support and political momentum consequent to mounting opposition to it. Just one example of how, in the end, it’s important not to mourn or lament but to organize!

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