Changing psychiatric perception of African Americans with psychosis

transcript

European Journal of American Culture Volume 27 Number 3. © Intellect Ltd 2008.Article. English language. doi: 10.1386/ejac.27.3.227/1

Changing psychiatric perception ofAfrican Americans with psychosisG. Eric Jarvis Çulture and Mental Health Research Unit

AbstractIn the years before the American Civil War, medical observers deemed psychosisto be rare in slaves, but common in free blacks of the North. After 1865, the pre-vailing psychiatric perception of African Americans was that psychosis wasincreasing at an alarming rate. Reasons for the increasing rates were initiallyascribed to the effects of emancipation, but as researchers reported rates of psy-chosis to be on the rise through the first half of the 20th century, the stress ofinternal migration and social adversity were increasingly invoked as explanatoryfactors. After 1970, however, attitudes influencing the psychiatric assessment ofAfrican Americans changed profoundly. Psychiatrists no longer reported differen-tial rates of psychosis by ethno-racial category. Observed racial differences wereattributed, instead, to misdiagnosis with clinician bias emerging as the principalcause. Hence, in the new way of thinking, African Americans were over-diagnosedwith psychosis, thereby creating a false impression of high rates. These changes inattitude and perception have taken place in the context of historical trends thathave increasingly viewed African Americans as equal to rather than inferior towhites. Links from past to present will uncover racial stereotypes that continue toinfluence the psychiatric diagnosis and treatment of African Americans today.

In the United Kingdom over the last forty years, high rates of psychosiswere reported in Caribbean and African migrants compared to the whitepopulation (Fearon et al. 2006). Psychosis carried with it significant socialstigma (Rao et al. 2007), socioeconomic decline (Silverton and Mednick1984), increased risk of involuntary hospitalization (Morgan et al. 2004),and potentially serious treatment side effects (McCue et al. 2006); beinglabelled with psychosis was not something to be taken lightly. Despite theserious consequences, reasons for the high rates of psychosis in blackBritons eluded discovery. To further confuse the issue, no comparableincrease in rates of psychosis was reported in the large African Americanpopulations of the United States (Hutchinson and Haasen 2004). Thisarticle set out to discover why the American literature was silent on thisimportant issue.

To the author’s surprise, answers were difficult to find. Discussion ofrates of psychosis in African Americans disappeared from the Americanpsychiatric literature almost forty years ago (Jarvis, 2007). Gradually it

KeywordspsychosisAfrican Americanhistoryratesdiagnosisstereotypes

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became clear that the interpretation of research findings with respect toAfrican Americans and psychosis changed significantly over time. Answerswere forthcoming only after careful consideration of the history of blacks inthe United States and their relationship to psychiatry. Medline and special-ized medical databases of old collections were searched using relevant key-words (Negro, coloured, black, or African American and insanity, dementiapraecox, or schizophrenia). The American Journal of Psychiatry was availableonline from 1844 as was Psychiatric Services, another high impact Americanjournal, from 1950. These sources were searched using the same keywords.The result was a small but significant record of the past that acted as awindow on the psychiatric perception of African Americans with psychosisfrom the 19th century to the present day.

A word on terminologyTerms for mental illness changed over the years, as have terms denotingracial categories. In 19th century North America, insanity was a generalterm used to describe severely disturbed behaviour. As a testament to thewidespread use of the word in professional circles, the American Journal ofPsychiatry was called the American Journal of Insanity until 1921. By theearly 20th century, insanity gave way to more detailed categories: dementiapraecox and manic-depressive disorder (Wallace 1994). The most severe ofthese, dementia praecox, was the precursor to schizophrenia, which replaceddementia praecox in the American psychiatric literature by mid-century.Manic-depressive disorder evolved to become bipolar disorder in the late20th century (Bauer 2003). General paresis of the insane referred to endstage syphilis. It was widely recognized that patients with terminal syphiliswere among those committed to psychiatric hospitals until antibiotic treat-ments drastically reduced the prevalence of the disorder (Frierson 2003). Inthe latter decades of the 20th century, schizophrenia became a well-knownand well-studied psychotic disorder. Schizophrenia and psychosis, althoughnot synonyms, were sometimes used interchangeably in the wider literature.Strictly speaking, psychosis was a general term of which schizophrenia, as adisorder characterized by psychotic symptoms, was a subset. Psychosisreferred to the ‘inability to distinguish reality from fantasy; impaired realitytesting, with the creation of a new reality’ (Kaplan and Sadock 1998: 281).To avoid confusion, this article favoured the general term psychosis whenreferring to all categories of severe mental illness in all time periods becauseit implied the presence of auditory hallucinations, delusional thinking, dis-ruptive behaviour, and other characteristic signs and symptoms of severemental illness regardless of underlying cause.

Racial terms also changed over the years. According to Bennett(2000), who reviewed racial categories used in the decennial United Statescensuses from 1790 to 2000, official 19th century terms for persons ofAfrican descent were slave (1790–1840), black or mulatto (1850–1890),Negro (1900–1960), black or Negro (1970–1990), and black, AfricanAmerican or Negro in 2000. Coloured (or colour) was a heading in the

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census from 1790 to 1970, while race became a census heading in the20th century. The medical literature generally followed these conventionsof terminology over the last 200 years. This article favoured the termsAfrican American or black when referring to persons of African ancestry,although slave and other words were used when appropriate.

Antebellum United StatesThe mental life of African Americans was largely ignored on the slaveplantations of the Old South (McCandless 1996). According to prevailingviews, psychosis among slaves was rare because mental illness in all of itsforms was seen as an affliction of the ‘civilized’ classes, who were subjectto the strains and increased mental activity inherent to civilization (Dain1964). African Americans, as a ‘primitive’ people, lacked sufficient mentalcapacity to engage fully in the rigorous demands of the modern world andso were theoretically exempt from psychosis, or at least were less likely tobecome psychotic (Raimundo Oda et al. 2005). Referring to AfricanAmericans, Bucke (1892: 65) wrote:

Doubtless if we had statistics of other backward and stationary people asimilar state of matters would be found – all such facts as we have leading tothe conclusion that among savages and semi-savages there exists compara-tively little insanity.

Apparent lack of psychosis among slaves reinforced contemporary views ofsocial hierarchy in which the highest level of mental ability resided inwhite men followed in descending order by white women, black men, andlast of all, black women (Loomba 2005). Psychosis among slaves wasexpected to occur infrequently, if at all, and only came to the attention ofphysicians when symptoms were severe and productivity was threatened.Quietly endured symptoms evaded notice, in part, because slave mastersand overseers assigned simple, routine work adapted to the limitations ofaffected slaves (Postell 1953). Succession records of the pre Civil War eranoted that mental and nervous disorders were present in African Americans,yet even ‘unsound’ slaves were sold for profit if they could work in someway (Postell 1970: 87). In other words, the value of slaves was often inde-pendent of mental state. It is not surprising, given these circumstances,that early accounts minimized the presence of psychosis in slaves.Psychiatric symptoms escaped notice as long as slaves fit into the routineof plantation life.

The earliest references to psychosis in African Americans were highlyvaried depending on the author’s position on slavery. Benjamin Rush, awell-known abolitionist, took a relatively sympathetic stance when henoted, ‘The Africans become insane, we are told, in some instances, soonafter they enter upon the toils of perpetual slavery in the West Indies’(Rush 1812: 41). Pro-slavery accounts, on the other hand, were remark-ably insensitive. According to McCandless (1996), for example, many slave

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owners and overseers openly accused slaves of being lazy or of feigningillness to avoid work. Cartwright (1851) went further by creating peculiardisease entities that he felt were unique to slaves: Drapetomania andDysaesthesia Aethiopis. Drapetomania was also known as The DiseaseCausing Slaves to Run Away and was purportedly caused by a ‘disease ofthe mind’ (p. 91) that overcame the common sense of slaves to remain inthe care of their masters. Cartwright seemed unable to consider any otherexplanation for a slave’s wish to flee captivity. To him, slavery was thenatural state of African Americans because he considered them to be likechildren and in need of constant care. For a slave to abandon her masterwas such a ridiculous notion to Cartwright, and the act so desperate, thathe created Drapetomania to explain the behaviour in a manner consonantwith his political and economic interests.

Dysaesthesia Aethiopis was also called Hebetude of Mind and ObtuseSensibility of Body, or Rascality. Symptoms included mental sluggishness orconfusion, difficulty staying awake, and violent outbursts with destructionof property. Cartwright noted in particular that slaves in this state of mindseemed ‘insensible to pain when subjected to punishment’ (p. 710). Onceagain, behaviour that threatened productivity captured the attention ofmedical authorities. Cartwright attributed the condition to ‘negro liberty’(p. 710), and he maintained that it was more common among slaves wholived, ate, drank and exercised like free blacks. As with Drapetomania,Dysaesthesia Aethiopis was created to explain the behaviour of slaves in amanner that would uphold the interests of slave holding whites.

Results of the 1840 census seemed to officially confirm low rates ofpsychosis in slaves. Drawing on this data, Edward Jarvis (1842a), a promi-nent physician and statistician from Boston, reported unexpected findings:free blacks in the Northern states had high rates of hospitalization forpsychosis – far higher than the rate for whites; while in the South, theslave populations had much lower rates than the white population. Thefindings became widely known as confirmed by a writer from the period(Anon 1851: 153):

I send you a copy of a few items from a statistical table which I compiledsome years ago from the U.S. Census of 1840, and published in a countrynewspaper, without obtaining much notice, although it exhibits, in a moststriking light, the amazing prevalence of insanity and idiocy among our freecolored population over the whites and the slaves.

On careful re-examination of the census data, Jarvis (1842b, 1844, 1852:269) discovered errors that were so vast as to call into question his earlierconclusions and the integrity of the census itself:

Soon, however, [the data] appeared to be so contrary to all previous experi-ence and observations, that some were led to examine into the character ofthe authority on which the tables were founded, and discovered that the

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whole of the statements in reference to the disorders of the colored race werea mere mass of error, and totally unworthy of credit.

Despite repeated attempts to bring these problems to the attention of thepublic, it was Jarvis’ initial report in 1842 that had struck a chord withSouthern writers who used the erroneous census data to promote the ideathat slavery was beneficial to the mental health of African Americans. Forexample, John C. Calhoun, a prominent Southern politician, cited the1840 census to argue his case with the British foreign minister thatslavery was beneficial to blacks in general (Calhoun 1844).

In summary, during the antebellum period, the mental health of slaveswas neglected for several reasons: (1) 19th century explanations of psy-chosis predicted low or absent rates in African Americans; (2) many slaveswith symptoms of psychosis could still be productively employed, therebyrendering their mental state irrelevant; (3) the mental state of AfricanAmericans, when it was described, became a political tool to justifyslavery; and (4) the low statistical rates of mental illness in slaves, as pub-lished in the 1840 census, bolstered arguments that slavery was beneficialto African Americans and should not, therefore, be abolished. The conflu-ence of these trends conspired to render black psychosis invisible beforethe Civil War.

Rapidly increasing rates of psychosis, 1883–1921Following emancipation, medical reports described a rapid decline in thegeneral health of former slaves. Chief among the reported changes wereincreases in rates of tuberculosis, syphilis and psychosis. Powell (1896:1186) attributed this trend to a loss of behavioural controls that had beenimposed on African Americans by slavery:

Freedom removed all hygienic restraints and they were no longer obedient tothe inexorable laws of health, plunging into all sorts of excesses and vices,and having apparently little control over their appetites and passions.

The medical community expressed alarm to such a degree that by the endof the 19th century there was concern that the African American racewould not long survive (Corson 1887). Although rates of psychosis amongblacks were noted to have increased from 1860 to 1890, they did not yetexceed the rates among whites. These findings mostly were reported byinvestigators from the former slave states: Roberts (1883) of Goldsboro,NC; Buchanan (1886) of Meridian, MS; Witmer (1891) of Washington,D.C.; Babcock (1895) of Columbia, SC; Powell (1896) of Milledgeville, GA;Miller (1896) of Goldsboro, NC; McKie (1897) of Woodlawn, SC; Evarts(1913) of Washington, D.C.; and O’Malley (1914) of Washington, D.C.Northern writers rarely addressed the issue; when they did, rates of psy-chosis in blacks were unremarkable (Kirby 1908). Drawing from themesof the debate begun by Edward Jarvis (1844, 1852), Southern physicians

linked the increasing rates of insanity among former slaves to the effects ofemancipation. Buchanan (1886: 68) recalled only beneficial effects ofslavery on African Americans when he wrote:

While the negro had a master he had no thought for the morrow; not asingle care burdened his mind; there was nothing to disturb his equilibrium,and he was always the same fat, sleek, and contented individual, flourishingin the tropical Southern sun like a healthy plant indigenous to the soil.

The obvious implication was that with masters to care for them, AfricanAmericans lived happier, healthier lives:

The regular, simple life, the hygienic conditions, the freedom from dissipationand excitement, steady and healthful employment, enforced self restraint,the freedom from care and responsibility, the plain, wholesome, nourishingfood, comfortable clothing, the open air life upon the plantation, the careand treatment when sick, in those days, all acted as preventive measuresagainst mental breakdown in the negro.

Drewry 1908: 312

These idealized recollections of African Americans in the Old South werecommon at the turn of the 20th century and revealed profoundly racistattitudes that blacks needed whites to protect them from poor hygiene,poor sanitation, excessive eating, excessive alcohol consumption anduncontrolled sexual relations. O’Malley (1914: 318) implied that the insti-tution of slavery shielded African Americans from these problems of excessby enforcing limits to their ‘animal appetites’. This perceived need ofimposed restraint was just one of the racial stereotypes that became part ofthe Southern medical literature by the end of the 19th century. Othersincluded a tendency to agitation (Cartwright 1851); a tendency to beaggressive and destructive when mentally ill (Cartwright 1851; Buchanan1886); a proclivity to be louder and less restrained when psychotic (Miller1896); a tendency to be dangerous (O’Malley 1914; Green 1914; Johnson1944); and a tendency to be inherently fearful and superstitious (Bevis1921). Green (1914) also suggested that African Americans were predis-posed to relatively severe forms of psychosis due to their perceived ten-dency to be suspicious, fear bodily harm, believe in witchcraft and thesupernatural, and attribute illness to poison.

Hence, by the beginning of the 20th century, Southern writers not onlyreported increasing rates of psychosis in African Americans, but also moresevere and disruptive forms of psychosis when it did occur. Emancipation,according to white physicians, freed the slaves to a condition of deterioratingphysical and mental health by virtue of their inability to exercise restraintand proper self-care. In the perception of health professionals, the naturaltendencies of blacks to suspicion, superstition, excitement and lack of emo-tional control predisposed them to psychosis. In general, blacks were felt to

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have lower rates of psychosis in what were undersood by whites to be lessdemanding environments, such as slavery compared to freedom and, later,living in the traditional South versus the industrial North.

High rates of psychosis: 1926–1961In the mid 20th century, researchers reported increasing rates of psychosisin African Americans from many parts of the United States, includingurban centers of the North: Pollock (1926) of New York state; Malzberg(1935, 1944, 1953, 1959) of Albany, New York; Wagner (1938), whocompared rates of psychosis in Cincinnati and New York City; Faris andDunham (1939) of Chicago; Ripley and Wolf (1947) who compared ratesof psychosis in black and white soldiers; Williams and Carmichael (1949)of Washington, D.C.; Frumkin (1954) of Ohio State University; Wilson andLantz (1957) of Charlottesville, VA; and Vitols (1961) of Goldsboro, NC.Furthermore, the reported rates were no longer merely increasing, butwere higher in blacks than in whites. Malzberg (1944: 376–377), a promi-nent psychiatric researcher of the time, referred to census data on mentalillness, including psychosis, when he wrote:

For the United States as a whole there was a rate of 56.5 per 100,000 generalpopulation. Negroes had a corresponding rate of 61.8. Thus, for the first time,Negroes showed a higher rate than the country as a whole. In all but four ofthe southern states Negroes had higher rates of first admission in 1933 thanwhites. This excess, it should be noted, was obtained despite the fact that dis-crimination in services for the Negro doubtless still existed. It would seem to bea fair inference, therefore, that in 1933 Negroes had relatively more mentaldisease than the white population.

The fashion to study African Americans with mental illness possibly wasstimulated by the Great Migration in which large numbers of Southernblacks moved to Northern cities after the First World War (Tindall 1988).In earlier years the mental health of blacks went unnoticed in theNorthern states, much as it had in Europe (Dain 1964), possibly becauseof small numbers of nonwhite minorities living in these areas. From theabove quotation by Malzberg, high rates of mental illness in AfricanAmericans became a mainstream finding by 1944 and were no longerconfined to the South. In addition, over time, the mainstream study ofmental illness in African Americans came to focus more and more on psy-chosis, and the distinction between rates of hospital admission and rates ofdisorder were blurred. For example, Malzberg (1935, 1944, 1953) foundthat general paresis of the insane (syphilitic psychosis) and alcoholicpsychoses were more common in blacks. He also observed higher ratesof dementia praecox (similar to schizophrenia) in African Americans.Wagner (1938) found higher rates of alcoholic and syphilitic psychosesamong blacks in Cincinnati and higher rates of functional psychosesamong blacks in New York City. In the same year, Cohen and Fairbank

(1938) of Maryland hypothesized that high rates of syphilitic psychosis inblacks accounted for the overall high rates of mental disease found in thisgroup. In a statement that captured the mainstream psychiatric percep-tion of African Americans for the next thirty years, Malzberg (1935) said:

In all the major psychoses, except the senile psychoses, the negro populationhas higher rates of first admission than the white population. The lower ratein the senile psychoses is due to the favorable age distribution of the negroes.When standardized, negroes have a higher rate than whites. (p. 512)

It is interesting to note how Malzberg qualified the statement about senilepsychoses by suggesting that rates of this disorder were higher in blacksafter controlling for age. This kind of finding could have easily goneunstated, but its inclusion is significant as yet another example of thefocus on high rates of psychosis in African Americans. Also of importancewas the tendency of these researchers to report blacks as having highrates of the most severe forms of psychosis, like dementia praecox andsenile psychosis, or of highly stigmatized forms of psychosis such as thosearising from alcohol or syphilis.

Explanations of the reported high rates and severity of psychosis inAfrican Americans included inherent emotional instability (Malzberg 1935),poverty (Malzberg 1944, 1953), and the strain of living as minorities inwhite-majority neighbourhoods (Faris and Duhnam 1939). These factors,among others, allegedly contributed to psychosis in the African Americanpopulation, but no explanation was so widely accepted as the persistentnotion that blacks developed higher rates of psychosis when they lived indemanding environments, such as the North compared to the South or inurban versus rural settings (Malzberg 1935: 472; Wexberg 1941; Ripleyand Wolf 1947; Sanua 1970: 305), when stressed by periods of rapidculture change (Wilson and Lantz 1957), or when faced with frustratedgoal-striving in environments of limited opportunity (Parker and Kleiner1966). These explanations represented reiterations of the Antebellum dis-course begun by Edward Jarvis (1842a) in which free blacks had highrates of insanity in northern states, supposedly due to the harsh climateand circumstances of life, whereas enslaved blacks of the South were vir-tually protected from insanity because they were suited to the milderclimate and to a life in which others provided for and protected them.When, on occasion, evidence pointed toward the unexpected finding ofwhites having higher rates of psychosis than blacks, the 19th century dis-course was invoked to give context and to explain. For example, Wexberg(1941: 2696) of Louisiana explained the results of his study by saying:

The definite white predominance observed in neurosyphilis, functional psy-choses and psychoneuroses is probably to be explained by the lower level ofcivilization and culture of the Negro race, particularly in the South, and thecomparative simplicity of their adaptations.

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According to the thinking of the day, when rates of psychosis were high inAfrican Americans it was due to their attempts to live in environmentsbeyond their natural capacity; when rates of psychosis in African Americanswere low it was due to their inferior civilization and culture – their literalinability to become mentally ill.

In summary, in the first half of the 20th century, rates of psychosisamong blacks were reported to exceed those of whites. The findings wereno longer confined to the Southern states, but generalized to major urbancentres of the North such as Chicago and New York City. Explanations ofthe findings seemed to rest on the following line of reasoning: AfricanAmericans were more primitive than white Americans. Consequently, theywere protected from psychosis when they lived in simple, unchallengingenvironments, but developed high rates of disorder when they left the tra-ditional life of the South for the harsh life of the North, a life for which, byimplication, they were ill-suited and which produced psychosis. In view ofthese ideas, little had changed in the mainstream psychiatric perception ofAfrican Americans from 1842 through the mid-20th century.

Transition from high to equal ratesBy the 1940s, the integrity of this worldview was starting to come apart.Fundamental changes were underway with respect to the way psychia-trists understood susceptibility to psychopathology. As already discussed,mental illness was conceived historically to be an affliction of ‘civilized’peoples. In contrast, Demerath (1942: 703) announced the following inthe American Journal of Psychiatry:

The idea that the functional pathologies are the peculiar curse of civilizedman, while the primitive enjoys perfect psychic health except for the inevitableorganic mental ‘diseases,’ is no longer tenable.

Other ideas, such as the notion of cultural exclusion gradually madetheir way into the psychiatric literature along with the implication thatAfrican Americans had been denied the opportunity to participateequally in the greater society (Brody 1967). With the advance of newideas, the traditional understanding of psychosis in African Americansbegan to change. Critics started to question the rigor and objectivity ofresearch and clinical work concerning African Americans (Rosenthal1933; McLean 1949; St. Clair 1951; Roberts and Myers 1954;Schermerhorn 1956; Pasamanick 1962, 1963, 1964; De Hoyos and DeHoyos 1965; Fischer 1969). This new way of thinking gathered momen-tum during the Civil Rights Movement and raised the possibility thatstatistical error, racism, clinician bias and misdiagnosis accounted forthe high or increasing rates of psychosis in African Americans that hadbeen reported for decades. Edward Jarvis’ efforts (1842b, 1844, 1852) todiscredit the findings of the 1840 census were at last gaining a perma-nent audience.

Rosenthal (1933: 317) disputed the statistical rigor of studies reportingdifferences in rates of mental illness by racial category:

Although much has been written on the problem of racial differences in themental diseases, very little of it will stand careful scientific statistical tech-niques or examinations. Until this becomes possible, no sweeping generaliza-tions are possible concerning the susceptibilities of races to mental diseases.

More than three decades later, Fischer (1969: 437) cast serious doubt onthe high rates literature with this unfavorable summary statement:

When the studies reviewed here are compared, with regard to both conclu-sions and methodological adequacy, not only is there clearly no evidencepointing to a causal relationship between being Negro and being mentallyill, but also there appears to be little substantial basis for concluding at thistime that even treated rates of mental illness in the Negro population are anygreater than treated rates in the white population.

Pasamanick (1962: 299) drew attention to the fact that African Americanshad been singled out for research more often than other minorities:

By far the most commonly studied group in this country has been the Negro.This is hardly surprising in view of his unique history, the passions arousedby this history, his condition in life, the recent assertions of his rights to theAmerican dream, and the fact that he constitutes the largest and mosthighly visible minority group.

Fischer (1969: 437–438) suggested that racism underlay the excess atten-tion given to African Americans and their allegedly high rates of psychosis:

As a likely answer to the question of why studies reaching this conclusion havereceived greater attention than studies reaching the opposite conclusion, oneneed only cite the pervasive racist atmosphere in the United States. Clearly,conclusions enhancing the development of the myth [of high rates of mentalillness] fit well with the prejudices and stereotypes of the white majority.

Faulty research methods and the specter of racism opened the door toproblems with the clinical process itself. If the world of research could makemistakes, then what about the clinicians who managed the day-to-daypsychiatric diagnosis and treatment of African Americans? St. Clair (1951:114) was one of the first to draw attention to the interaction betweenAfrican American patients and the predominantly white professionals whotreated them:

The Negro would seem to mistrust the white physician. This feature of suspi-ciousness might appear to give a paranoid coloring in some individual

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patients, but it was found to be so frequent and to be so separate from realparanoid material that it would certainly suggest that it is attributable to thefact of Negroes mistrusting and resenting white men, the therapist beingwhite.

St. Clair’s observations raised the uncomfortable possibility that whiteclinicians could be misinterpreting the behaviour and symptoms of blackpatients and that the accurate psychiatric diagnosis of African Americansrequired careful attention to context. Pasamanick (1963: 77) furtherhighlighted the unstable nature of psychiatric diagnosis when he noticedan inverse relationship between rates of manic-depressive psychosis andschizophrenia among blacks in Virginia over time:

If the tabulations for manic depressive psychoses over the years are studied,it is found that in Virginia a proportionate fall has occurred as schizophreniarose. In 1940 there was 2.5 times as much manic-depressive psychosis asschizophrenia. When the two rates are summed, the total rate is invariantacross the years, from 28.5 per hundred thousand in 1920 to 27.2 in 1955.What has apparently occurred is a change in style of diagnosis rather thanan increase in Schizophrenia.

The implication of this statement was that psychiatric diagnosis of AfricanAmericans was dependent upon, or at least influenced by, fashion or style.To make matters even worse, alarming results were published in the US-UK Diagnostic Project, a landmark study that compared psychiatric diag-nosis in New York to psychiatric diagnosis in London, England. Cooperet al. (1972: 139) reported:

. . . The differences between the diagnostic statistics of New York and Londonhospitals are largely the result of gross differences between the diagnosticcriteria used by psychiatrists in the two cities. The most important of thesedifferences is that the New York concept of schizophrenia is much broaderthan that used in London and embraces many patients who would beregarded by British psychiatrists as suffering from depressive illnesses, neu-rotic illnesses or personality disorders, and nearly all those who would beregarded as suffering from mania.

The authors called into question the ability of American psychiatrists toaccurately diagnose schizophrenia, a point that was driven home in moredramatic fashion by the embarrassing conclusion that ‘. . . The New Yorkconcept of schizophrenia is not a useful one and is likely to inhibit fruitfulresearch if it is widely adopted’ (Cooper et al. 1972: 125). Murray (1979:256) affirmed this statement when he wrote, ‘No area of psychiatric practicehas attracted more criticism from overseas than American diagnostic habits’.

Hence, in the middle decades of the 20th century, the long-held beliefthat African Americans had high rates of psychosis came into question.

The Civil Rights Movement, and the fight to end racial segregation, pro-vided a social environment conducive to the re-evaluation of accepted atti-tudes with respect to African Americans and psychosis. Many AfricanAmericans came to doubt the good intentions of the medical establish-ment when biased practices of medicine, psychiatry and research wereexposed (Lawson 1986; Suite et al. 2007). In addition, the unflatteringfindings of the US-UK Diagnostic Project (Cooper et al. 1972) prodded theAmerican Psychiatric Association to standardize the diagnosis of mentaldisorders by introducing the Diagnostic and Statistical Manual of MentalDisorders, 3rd Edition (American Psychiatric Association 1980; Spitzer2001; Spitzer, Williams and Skodol 1980). Diagnostic accuracy in AfricanAmericans, not to mention the accuracy of rates of psychosis, had becomeuncertain at best; and at worst, given the explosive nature of race relationsin the United States, dangerous terrain to be gingerly negotiated in thenew American society.

Equal rates of psychosis: 1965–2007In the desegregated world of equal rights among the races, high rates of psy-chosis in African Americans came to be understood as artefacts of misdiag-nosis due to clinician bias and error (De Hoyos and De Hoyos 1965; Simonet al. 1973; Adebimpe 1981; Mukherjee et al. 1983; Jones and Gray 1986;Neighbors et al. 1989; Strakowski 1993, 1995, 1996a, 1996b, 2003; Chenet al. 1996; Neighbors et al. 1999, 2003; Minsky et al. 2003; Barnes 2004;American Psychiatric Association Practice Guideline 2004; Blow et al.2004; Trierweiler et al. 2005; Ahuja, Jarpa and Trachtman 2007; Williamsand Earl 2007). Underlying these findings was the hope that differentialrates of psychosis would disappear if unbiased psychiatric diagnosis could beevenly applied in all settings. As a result, diagnostic issues became para-mount with respect to race and psychosis. As an example of this shift awayfrom rates of disorder, Snowden and Cheung (1990: 349) wrote about ratesof diagnosis of schizophrenia rather than rates of schizophrenia per se:

The most striking differences were found in connection with schizophreniaand the affective disorders. For all types of inpatient organizations, schizo-phrenia was diagnosed more frequently among Blacks than among Whites. Therate of diagnosis of schizophrenia was sometimes almost twice as great amongBlacks as among Whites. (Italics added)

It is easy to imagine that had this article been published in 1950, ratherthan 1990, the authors would likely have been discussing rates of disorderrather than rates of diagnosis. A decade later, the American PsychiatricAssociation (2004: 31) drew official attention to diagnostic dilemmas inits Practice Guideline for schizophrenia:

Compared with Caucasians, African Americans, especially men, are lesslikely to receive a diagnosis of a mood disorder and more likely to receive a

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diagnosis of schizophrenia . . . These remarkably consistent findings suggestthat clinicians should be mindful of the extent to which cultural factorsinfluence their diagnostic approach.

Statements such as these were bolstered by reports that African Americanswere more likely to receive a diagnosis of psychosis in clinical than inresearch settings, implying that the objective standards imposed by researchevaluations reduced the bias inherent to routine clinical practice(Strakowski, Shelton and Kolbrener 2003; Neighbors et al. 2003; Trierweileret al. 2005). Furthermore, Chen et al. (1996) found that stability of diagno-sis was less in African American inpatient populations, with blacks beingmore likely over time to receive a change of diagnosis from mood disorders toschizophrenia. These findings, along with many others, implied that clini-cian bias, leading to misdiagnosis, accounted for inflated rates of observedpsychosis in African Americans. Potential examples of clinician bias began toappear in the psychiatric literature: De Hoyos and De Hoyos (1965) foundthat social distance between white clinicians and black patients led to errorsin the reporting of symptoms; Adebimpe (1982) reported that AfricanAmericans with schizophrenia were judged to exhibit more severe anger,impulsive behaviour and hallucinations than white patients with schizo-phrenia; Jones and Gray (1986) suggested that African American language,mannerisms and style of relating were easily misunderstood by white clini-cians, who also misinterpreted cultural mistrust as paranoid symptoms ofpsychosis (Whaley 1998, 2004a, 2004b; Whaley and Geller 2003); andwhite clinicians reported more chronic symptoms of psychosis in theirAfrican American patients (Strakowski, Shelton and Kolbrener 2003) aswell as more auditory hallucinations than in white patients with the samedisorder (Arnold et al. 2004a,b; Patel et al. 2006). Despite these findings,and a growing awareness of potential clinician bias, problems of misdiagno-sis did not entirely disappear with the use of sophisticated research inter-views (Strakowski, Shelton and Kolbrener 2003; Neighbors et al 2003;Trierweiler et al. 2005). As Strakowski, Shelton and Kolbrener (2003: 747)reported, ‘Unfortunately, the specific reasons why clinicians overdiagnoseschizophrenia in African Americans remain uncertain’.

Despite the uncertainty, this bedrock position of misdiagnosis becameso fundamental that even when large-scale studies suggested high rates ofpsychosis in African Americans, the possibility was either downplayed oroutright dismissed. One important example of this practice was in theschizophrenic disorders chapter of the Epidemiologic Catchment Areastudy (Keith, Regier and Rae 1991: 41):

Controlled for age, gender, marital status and, most importantly, SES level, thesignificant difference between black and white prevalence rates disappears.

As mentioned by the authors, differential rates of psychosis between blacksand whites disappeared after controlling for socioeconomic and other

variables. Instead of exploring and discussing the complex interactionsamong race, social class and mental illness, the authors ended the sectionwith the following comment:

Hence the higher rates which appear for the black population may well beexplained by the confounding variables of lower socioeconomic status andhigher rates of marital separation or divorce, which are independently asso-ciated with higher rates of schizophrenia. Of course, in a cross-sectionalstudy such as this one, it is not possible to state definitively that currentmarital status and socioeconomic status explain the relations between raceand disorder, because schizophrenia can lead to poor job status and maritalbreakup.

(Keith, Regier and Rae 1991: 41)

The authors acknowledged that the cross-sectional nature of their studylimited its ability to explain the relationship between race and rate of dis-order, but they did not suggest that truly elevated rates of psychosis were apossibility in African Americans, an important change from what wouldlikely have been concluded less than forty years earlier. The tendency toexplain differential rates of psychosis in terms of misdiagnosis continuedin an article by Barnes (2004: 250) in which the author avoided theconclusion that admission rates of schizophrenia were higher in AfricanAmericans than in whites:

In summary, the study findings indicate that in comparison with their pro-portion in the general adult population of Indiana, African Americans wereoverrepresented among individuals admitted to state psychiatric hospitalswith diagnoses of schizophrenia. In comparison to Whites admitted to statepsychiatric hospitals, African Americans were overdiagnosed with schizo-phrenia and underdiagnosed with mood disorders.

Minsky et al. (2003: 643), documenting rates of mental disorder amongvarious minority groups in New Jersey, found higher rates of psychosisamong African Americans, and attributed the difference to ‘ambiguities inthe patient-clinician interaction’. A number of alternate explanations werebriefly entertained in the discussion of the article, including ‘charactertraits developed by minorities in response to a particular environment, anddifferences in genetic and biological vulnerability’, but not the possibilityof elevated rates in one ethno-racial group over another. Adding to the dis-cussion, the American Psychiatric Association (2004: 31) concluded:

While it is possible that such differences may reflect actual illness variationamong racial/ethnic groups, there is growing evidence that cultural differ-ences in symptom and personal presentation, help seeking, interpretation ofsymptoms and clinical judgments by (usually Caucasian) clinicians, andtreatment referral are likely causing race-linked biases in diagnosis.

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This position statement clearly sided with the misdiagnosis perspectiverather than actual illness variation among the races, a view that dominatedthe American psychiatric literature for almost four decades. In recent years,new terms such as ‘disparities of diagnosis’ appeared in the literature (Blowet al. 2004; Ahuja, Jarpa and Trachtman 2007). Disparities of diagnosiswere an outgrowth of the wider debate on health care disparities in theUnited States, which operated on the assumption that all sectors of the pop-ulation should have equal access to services (Mead et al. 2008). Disparitiesof diagnosis implied that psychiatric diagnoses, like all other medical com-modities, should be equally available to all groups. As an example,Bresnahan et al. (2007) linked their finding of high risk of schizophrenia inAfrican Americans to the problem of health disparities rather than focusingon illness variation among ethno-racial groups.

Hence, since 1970, reported differential rates of psychosis among blackand white Americans all but disappeared from the psychiatric literature.Instead, misdiagnosis explained differential rates in clinical settings eventhough rigorous research methods failed to eliminate misdiagnosis ofAfrican Americans with psychosis. Given these findings, misdiagnosis andelevated rates of psychosis in African Americans were alternate explana-tions of the same data, the latter of which became unacceptable in recentdecades due to its historical association with the racist past.

Persistent stereotypes: uncovering the future pastCoincident to the preoccupation with misdiagnosis of psychosis in NorthAmerican Psychiatry was the neglect of the relationship among race, eth-nicity, social issues and mental illness. In the United States, presumedequal rates of psychosis among the races meant that social causes of psy-chosis were of secondary importance (Jarvis 2007). Lawson (1986: 50)made the same point in a slightly different way:

Although historically research findings about racial and ethnic issues were alltoo often used to support prevailing concepts of racial inferiority . . . in recentyears there has been an apparent trend toward disregarding racial and ethnicconcerns. More than a decade and a half ago a group of black residentscoined the term ‘hallucinatory whitening’ to describe the substitution of a‘colorblind’ view of psychiatry for what they perceived as a racist one.

The ‘hallucinatory whitening’ of North American psychiatry has con-tributed to an unwillingness to openly confront issues of race and racismamong other social issues. The result of this neglect has been the tacit per-petuation of 19th-century stereotypes that affect the general understand-ing, diagnosis, and treatment of African Americans with psychosis.

One such stereotype was the perception that African Americans wereinherently susceptible to greater numbers and severity of psychotic symp-toms than their white counterparts even in the absence of a formal diag-nosis of psychotic disorder (Kwapil et al. 2002; Frueh et al. 2002; Barrio

et al. 2003; Cohen et al. 2004; Arnold et al. 2004a,b; Patel et al. 2006).There has been ample precedent for this perception in the older psychiatricliterature of the United States. To cite a few examples, Cartwright (1851:693) observed that African Americans ‘can agitate every part of the bodyat the same time,’ something he called ‘dancing all over’. Buchanan (1886:68) recorded that free blacks practiced religion with ‘wild and hystericalshouting’, and ‘it is not an uncommon thing, when their minds are over-wrought by this kind of excitement, for them, during these meetings, to gointo the trance state’. Miller (1896: 7) said, ‘The negro laughs louder,sings louder, prays and preaches louder, than the Caucasian; and is morevulgar in speech and less cleanly in his person. He carries these character-istics into his insane condition and is therefore more noisy, more vulgarand beastly in his habits’. Bevis (1921) felt that African Americans wereparanoid and suspicious by nature. Referring to religious services, hewrote, ‘Behavior at these times appears to be only a step from the manicphase of manic-depressive psychosis or a catatonic excitement’ (p. 72).Lewis and Hubbard (1930: 815) concluded the following: ‘The negromanic-depressive, so-diagnosed, as a group tend with subsequent psychosesto differentiate into the deeper regression types of psychoses, for example,dementia praecox forms, and to terminate in such a state’. These descrip-tions of behaviour in African Americans revealed what their white authorsfelt to be salient features: excessive movement and loudness, emotionalintensity, religious practices bordering on psychosis and, when mentallyill, a tendency to severe symptoms and disorders.

Although these statements represented views of long ago, surprisinglysimilar attitudes remained in the modern psychiatric literature as seemingvestiges of earlier times. For example, Chen et al. (1996) presented data onchanges of diagnosis in psychiatric patients over a 7-year period. They foundthat African Americans with an initial diagnosis of schizophrenia tended toremain as such; but African Americans with mood disorders were morelikely to have their diagnosis change to the most severe form of psychosis:schizophrenia. Cohen et al. (2004: 864) reported: ‘Among blacks, responseto stressors may be expressed through increased paranoid ideation and psy-chotic symptoms’. Arnold et al. (2004a: 211) reported similar findings: ‘Thepresence of more prominent psychosis and first-rank symptoms of psychosisin African-American men may lead to an overemphasis of the psychosis anddisproportionate rates of schizophrenia diagnoses’. Most recently, Patel et al.(2006: 97) said: ‘The results of our study, which concur with previousresearch in adults, suggest that African-American adolescents with bipolardisorder may be more likely to present with, or be identified with, psychoticfeatures’. Although the offensive descriptions and blatant racism of pastyears disappeared, similar themes emerged albeit in muted form: AfricanAmericans exhibited an excess of psychotic symptoms with a tendency tosevere disorders and poor outcomes. These excerpts from the modern litera-ture were remarkably in tune with the following quotation about AfricanAmerican psychosis written almost one century ago by Green (1914: 707):

242 Eric Jarvis

The fear of the supernatural, the suspicions of his fellows and the necessityof guarding at all times against bad luck and the machinations of enemies,each of these factors may play a part in bringing about a psychosis whichmore frequently than in the white takes the form of dementia praecox.

A second stereotype was the belief that African Americans cannot takecare of themselves because, if left alone, they will become victims of theirown excesses (Cartwright 1851; Mays 1897). In the words of O’Malley(1914: 317), ‘The authority to which this race submitted as slaves had arestraining effect on them’. The perceived need to impose external controlson African Americans persisted to the current day. The following exampleswere of comparisons between blacks and whites: African Americans weremore likely to be imprisoned (Wolff, Blitz and Shi 2007); were more likelyto be considered dangerous when psychotic (McNeil and Binder 1995);had higher risk of involuntary hospital admission (Sanguineti 1996); weremore likely to be brought to emergency services by police or ambulancewhen psychotic (Jarvis et al. 2005); were more likely to be placed in seclu-sion in forensic inpatient settings (Price, David and Otis 2004); and wereoverrepresented among inpatients diagnosed with schizophrenia in statemental hospitals (Barnes 2004). The relationship in the North Americanpsychiatric literature between being African American and having contactwith agencies of social control was present and enduring.

A final stereotype was the kind of treatment deemed sufficient forAfrican Americans with medical and psychiatric illnesses. In his review ofblack mental illness in 19th century Alabama, Hughes (1992) docu-mented that it was the least experienced physicians who were assigned tocare for black patients with psychosis. More than one hundred years later,Bach et al. (2004) reported similar findings: compared to physicians treat-ing white patients, doctors working with black patients had less trainingand reported greater difficulty finding specialized care for their patients.Furthermore, recent reports indicated that African Americans with psy-chosis were more often treated with older psychiatric medications in theform of intramuscular injections (Arnold et al. 2004b; Kilbourne andPincus 2006; Shi et al. 2007), possibly deriving from stereotypes ofAfrican Americans as mentally and emotionally unable to benefit fromhigher order therapies such as psychotherapy (see Johnson 1944: 3). Thelegacy of inferior psychiatric treatment of African Americans lent credibil-ity to the conclusion that the psychiatric perception of African Americanswith psychosis remained influenced by 19th-century stereotypes.

Cross-Atlantic implicationsReported rates of psychosis in African Americans varied over time. Farfrom being an objective observed phenomenon, historical and politicalprocesses, in addition to long-held racial stereotypes, played importantroles in determining how psychiatric research was formulated and howfindings, such as rates of psychosis, were produced, interpreted and reported.

Given these findings in the United States, caution should be exercised byresearchers in the United Kingdom and other countries before acceptingwithout question research findings of high rates of psychosis in recentlyarrived black populations. Indeed, given that high rates of psychosis werereported in African Americans during and after the Great Migration, it maynot be surprising that following the large-scale migration of Caribbean andAfrican nationals to the United Kingdom after WWII, British researchersreported rates of psychosis in black Britons to be among the highest in theworld (Harrison et al. 1988; Fearon et al. 2006). It is also interesting tonote that the conclusions of current British reports were reminiscent ofAmerican findings fifty years ago in which elevated rates of psychosis inAfrican Americans were attributed to the effects of social factors such asmigration, poverty and discrimination. It may be that White Euro-centricsocial institutions, such as medicine and psychiatry, in the United Statesand United Kingdom shared common heritages of understanding andevaluating blacks with psychosis. Given the American experience, as racerelations in Europe evolve over time, preoccupation with rates of psychosismay diminish, while interest in diagnostic bias may increase. Sanua(1970: 304) called for a comparison of the North American and Britishexperiences with respect to high rates of psychosis in black populations:

The relatively high rates for Negroes immigrating to England as compared tothe native white English population is attributed to the fact that they sufferfrom discrimination in England. Having in mind the differences in ethniccomposition of the population in England, and the United States, a compari-son of the adaptation of the West Indian Negro living there would be of greatinterest.

Over the last 40 years, no such comparison was undertaken.

Concluding statementIn the Antebellum United States, low rates of psychosis were reportedamong slaves and high rates among free blacks of the North. Commonexplanations were that African Americans were unable to care for them-selves and needed slavery to ensure proper care. From 1883 to 1921, rapidincreases in rates of psychosis were noted among Blacks in the South.Reasons for the increased rates were judged to be due to the effects ofemancipation and were used to retrospectively justify slavery as a benevo-lent institution. During the years 1926 to 1961, researchers from theNorthern states frequently reported high rates of psychosis in blacks, find-ings that coincided with the Great Migration in which large numbers ofAfrican Americans moved to industrial Northern cities for the first time.From 1933 to 1972 old perceptions and attitudes were questioned as theCivil Rights Movement intensified. After 1965, high rates of psychosis inAfrican Americans disappeared in favour of equal rates among the races, aphenomenon that took place at a time when the United States was trying

244 Eric Jarvis

to repair the wrongs of slavery and segregation. The history and politics ofthe United States influenced the psychiatric perception of African Americanswith psychosis and must be understood to give context to clinical andresearch findings. Without historical context to guide psychiatric evalua-tion and treatment of African Americans with psychosis, patients willsuffer, as in the past, at the hands of well-meaning professionals who aretrying to help.

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psychosis’, European Journal of American Culture 27: 3, pp. 227–252, doi:10.1386/ejac.27.3.227/1

Contributor detailsG. Eric Jarvis studied medicine at the University of Alberta and pursued specialtytraining in transcultural psychiatry at McGill University. He is director of theCultural Consultation Service, Team Leader of the First-Episode Psychosis Program,assistant professor of psychiatry at McGill University, and a research associate ofthe Jewish General Hospital. His clinical and administrative work is closely tied to

his research interests: (1) the relationship between psychosis and culture and(2) the process of cultural consultation. Dr. Jarvis is also interested in cross-national comparison of psychiatric theory and practice. Contact: Culture andMental Health Research Unit, Institute of Community & Family Psychiatry, JewishGeneral Hospital, 4333 Cote Saint Catherine Road, Montreal, Quebec, CanadaH3T 1E4. Tel: (514) 340-8210.E-mail: eric.jarvis@mcgill.ca

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Changing psychiatric perception of African Americans with psychosis

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