While employed as a psychiatric social worker at an inpatient facility in Florida, I witnessed the intersection of racism and psychiatric practice. I observed the danger of a single story, which is the hegemonic biological explanation for mental disorders. In a compelling TED Global Talk Nigerian novelist, Adichie expounded upon what she termed ‘the danger of a single story’. Drawing from her experiences as a growing child in Nigeria, she explored the subtle ways power structures tend to make a single perspective the most definitive way of understanding a concept – thus marginalising other perspectives and knowledge frameworks.
Reflecting on my time as a psychiatric social worker, I recall a patient named Jamal, an African-American man in his late sixties. Jamal arrived at the hospital in an orange jumpsuit because he got diverted from the prison system. Jamal had a long history of smoking crack. In a treatment meeting, the psychiatrist spoke to Jamal in a paternalistic tone and said: ‘You have schizophrenia and you need to take your medication.’ Jamal replied back: ‘I ain’t got no damn schizophrenia; that shit is racist!’ Jamal was very hostile and angry toward the psychiatrist. Jamal went from a polite, courteous older gentleman to a Dave Chapelle caricature of a ‘crackhead’ in a matter of seconds. The treating psychiatrist was viewing Jamal’s behaviour from the medical gaze of psychiatry. The doctor framed Jamal’s behaviour as arising from his inner world rather than being motivated by the features of the situation. Observing the situation, it was apparent that his emotional state was driven by feeling subjugated by the psychiatrist.
Jamal exhibited symptoms of psychosis and paranoia, which are often attributed to the ‘disease of schizophrenia‘. Jamal would spend most of his days pacing the walls of the psychiatric ward and talking to himself.
However, an alternative explanation is that his symptoms could be attributed to witnessing violent events on a regular basis and his paranoia could represent a fear of being harassed by law enforcement, which is a legitimate fear living in his neighbourhood. Jamal was from Overtown, a historically black section of Miami that has a long-standing history of violence and drug trafficking. When I spoke to Jamal like a regular person, he was very polite and courteous. An alternate explanation for his presenting symptoms is that they could have been caused by smoking crack for many years.
Chronic consumption of cocaine can induce transient psychotic symptoms, expressed as paranoia or hallucinations. If crack had caused his symptoms of psychosis by altering the structure of his neurons, the logic is shaky as to why he would be administered Haldol, an antipsychotic that has been proven to promote the death of neurons. The traditional argument is that Jamal needs to take his medication because he represents a danger to society when his ‘illness’ is ‘untreated’. However, an alternative explanation is that psychiatry’s role in society is that of social control: Jamal is misbehaving, and the role of medication is to control his deviant behaviour.
The psychiatrist explained Jamal’s defiance as a feature of his disease and that he just needs to accept his diagnosis and take his medication. The prevailing narrative around the hospital is that the essential variable in whether a patient would be stable in the community was whether they were compliant with their ‘medication’. It is commonly stated that patients refuse their medication because they lack insight into their illness rather than finding the medication unhelpful with many unpleasant side effects. Like the prison systems, African-Americans are overly represented in inpatient psychiatric facilities. African-Americans continue to be over-represented in emergency and inpatient services, and this has been affirmed by the data.
Psychiatric facilities are extremely oppressive institutions. A person can be involuntarily committed based on an interview with a mental health professional. In practice, an individual can have their freedom taken away without ever committing a crime; they just have to be determined as a danger to self or others. Currently, in the US, we are coming to an agreement that it is not helpful to incarcerate non-violent offenders. We have also identified that the majority of people that fill the prisons are persons of colour. What I fear is by reducing the use of our prisons, we are going to increase the use of forced psychiatric care. It is especially ironic that the mental health system is being asked to solve the problems of the prison system, given that the primary treatment – if not the only treatment offered or forced against a person’s will – consists of psychotropic drugs many of which are sold on the street. Modern-day psychiatry has not left behind its legacy of racism.
The public mental health system in the US functions as a regime of control and repression just like the prison system targeting African-Americans and other people of colour disproportionately for coercive and intrusive interventions such as electroshock treatment, medication with high doses of brain-damaging drugs, commitment to institutions, and the use of restraints and solitary confinement. These are complex issues that require creative solutions. There are no easy answers to these problems. My intention in writing this is to spread awareness regarding the intersection between racism within the prison system and inpatient psychiatric care and prompt dialogue about these salient issues.
Jeff Friedman is a licensed clinical social worker. He is passionate is about spreading awareness of how trauma is at the root of most mental health and substance abuse problems.