It seems like every other major American institution is apologizing for racism these days, so why not the American Psychiatric Association (APA)?
Back in January, the APA issued an apology for its “ingrained” racism towards black and indigenous people of color (BIPOCs). The APA pledged to develop “anti-racist policies that promote equity in mental health for all.” Dr. Cheryl Wills, who chaired a task force studying racism in psychiatry, called on the APA to ensure that a “new generation of Black psychiatrists” will be “valued and seen.”
The APA’s apology caught the attention of The New York Times. “Psychiatry Confronts Its Racist Past,” the paper’s headline ran on April 30. The APA has “a lot to apologize for,” added the Times.
As someone who has been researching and publishing in the history of psychiatry for over 30 years, I agree that the APA has a lot to apologize for. But not for “structural racism.”
As long as the APA and the Times are searching for the proverbial root causes of the organization’s past failures, they’d be better off looking into the epistemological crisis that has haunted American psychiatry since its origins in the early 19th century. Put another way, by historian of psychiatry Andrew Scull, the most serious and ingrained characteristic of psychiatry is its ignorance about the disorders it claims to diagnose and treat.
The New York Times story wasn’t just another tiresome example of how the charge of racism often distorts the past. The allegation that BIPOCs are uniquely victimized by the APA is also a risible misreading of its own history.
It goes without saying that since the early 19th century, when psychiatry was chiefly practised in large hospitals then called asylums, American psychiatrists have uttered occasionally regrettable statements stereotyping blacks. But it’s quite another thing to say that historically American psychiatrists have been engaged in mass “pathologizing” of Black people, which is the word used by the Times.
In fact, prior to the 20th century, white psychiatrists rarely had much to do with African Americans, who were most often denied admission to asylums or relegated to segregated institutions. Outside of the Deep South, the 19th-century black community was usually too small to warrant much interest among white psychiatrists.
What genuinely interested 19th-century psychiatrists were their dealings with Irish Catholic immigrants, who flooded the wards of their asylums due to their alleged fondness for drink and propensity to psychosis. Psychiatrists were almost all Protestant white men (many were Unitarians or Quakers) and took a dim view of their Irish patients.
As one mid-19th-century psychiatrist noted, the Irish were “persons of exceptionally bad habits” and “of a low level of intelligence, and very many of them have imperfectly developed brains.” To many psychiatrists, the tainted heredity of Irish asylum inmates was responsible for their low cure-rates.
When the second wave of immigration hit America’s shores, beginning in the 1880s, it was Catholic and Jewish newcomers from Eastern and Southern Europe who drew the most attention from psychiatrists. As with the earlier Irish immigrants, psychiatric attitudes tended to be less than generous. Terms like “degenerates” and “defectives”—borrowed liberally from contemporary social Darwinist and eugenic terminology—often characterized descriptions of these immigrants who ended up in America’s mental hospitals.
Thus, it is simply a distortion of history to imply the chief ethnocentric crime of psychiatrists was their anti-black prejudice. In any case, harping on statements about patients’ ethnicity distracts attention from the truly systemic problems plaguing psychiatry.
Since the early 19th century, psychiatry has had to grapple with a predicament it shares with no other medical specialty. Psychiatrists treat patients suffering from mental or emotional disorders, whose symptoms—hallucinations, delusions, phobias, obsessions, anxieties, depression, for example—are their clinical stock and trade. The problem is that there are no blood tests or x-rays for these symptoms. While oncologists or cardiologists can cite measurable anatomical or physiological evidence to determine the causes of disease, psychiatrists may refer to vague changes in brain chemistry or anatomy, but the relationship between symptom and organic cause remains a persistent mystery to this day.
The cosmic joke at psychiatry’s expense is that as soon as a mental condition is shown to be due to somatic origins—a diet low in niacin accounting for the psychological symptoms of pellagra or the micro-organism responsible for tertiary syphilis—a different branch of medicine (most often neurology) takes it over and psychiatrists typically go back to treating people with schizophrenia or bipolar illness.
Psychiatry’s longing to show that its connection to the body is genuine has led to many unfortunate experiments in therapy down through the ages. In the hopes of demonstrating that mental illness is not a disorder of the mind, psychiatrists have resorted to methods such as applying electrical shocks to the head. Patients have been injected with malaria or insulin to produce similar shocks to the brain. In the belief that infected body parts can produce mental illnesses, surgeons once removed ovaries, teeth, tonsils, colons, and gallbladders. Surgeons have also severed connections in the brain’s pre-frontal cortex, a procedure often called a lobotomy.
These stabs at effective treatments have not all been dead ends—electroconvulsive therapy can mitigate clinical depression—but most did little to relieve patients’ symptoms and some did irreparable harm. They were performed less out of a desire to punish minorities than out of desperation.
Psychiatry’s so-called “somatic therapies” were followed in the 1950s by breakthroughs in drug treatments, including the introduction of chlorpromazine for psychosis, diazepam (Valium) for anxiety, and then the selective serotonin reuptake inhibitors (SSRIs) for depression. As a result, American psychiatry today enjoys cozy relations with the country’s powerful pharmaceutical companies. What the Times calls “over-reliance upon the use of antipsychotic medications” occurs alongside the mass prescription of antidepressants.
Psychiatry is thus part of what health critic Charles Medawar calls “Pharmageddon… a gold-standard paradox: individually we benefit from some wonderful medicines while, collectively, we are losing sight and sense of health.” Historian and psychiatrist David Healy calls this trend the “pharmaceuticalization” of everyday life, and “a relentless degradation of medical care.”
“Pharmaceuticalization” shows up in American popular culture. As Tipper Gore, the ex-wife of then-Vice President Al Gore, told the press in 1999 about her own bout of depression, “what I learned about it is your brain needs a certain amount of serotonin and when you run out of that, it’s like running out of gas.” Tipper Gore, like so many Americans keen to believe that depression is a legitimate disease similar to diabetes or HIV/AIDS, fell prey to drug advertising, which says that pills will make you feel better because you lack a certain neurotransmitter.
Psychiatry’s current shortcomings don’t end there. As the Times correctly observed, many psychiatrists opt out of commercial, Medicare, and Medicaid insurance plans because reimbursement rates are lower than for other medical specialties, which is a reflection of the fact that insurers view mental health care as a bottomless pit. They may be right. The current bible of American psychiatry, the fifth edition of the Diagnostic and Statistical Manual of Mental Diseases (DSM), is 947 pages long, weighs over three pounds, and consists of 312 separate mental diseases, including “hoarding disorder” and “disinhibited social attachment disorder” (in other words, a child becoming too familiar with weird old Uncle Fred). The first DSM, in 1952, contained just 60 disorders.
Over 70 percent of the people responsible for the contents of the new DSM edition reported direct drug industry ties. DSM-5’s length is one reason critics claim it “medicalizes” behaviors and moods which were once accepted daily occurrences.
Additionally, psychiatry has suffered traditionally from the fact that its patient pool mainly consists of people with severe mental disabilities whose behavior is often erratic and sometimes violent. When combined with psychiatry’s dismal therapeutic success, this factor helps explain its low prestige among medical specialties. Recruitment is a major challenge. As a black psychiatrist told the Times, “some people in my family even now won’t say that I’m a psychiatrist.” A family member told her she was “letting the family down” by not entering another specialty. The Times would like us to believe her family’s reaction was due to the profession’s “racism,” but history tells a different tale.
This overview of the APA and the history of psychiatry is not meant to stigmatize the numerous men and women who over the years have lent their impressive intellectual powers to the study and treatment of people with mental disabilities. I have written of some of them who, under sometimes appalling working conditions, showed remarkable insight and true compassion towards unfortunate fellow human beings.
Nor is a historical reckoning intended to suggest that the APA should ignore anti-black prejudice where it surfaces. If blacks are disproportionately diagnosed with schizophrenia, as the APA’s critics insist, that is a matter which deserves serious study.
Nonetheless, in 2021, psychiatry overall is a mess, the product of a past punctuated with failures that go far beyond the usual racial fault lines. What the history of psychiatry teaches us is that highlighting the challenges U.S. blacks face when it comes to mental disabilities or admission to the profession ultimately distracts attention from the field’s inherent shortcomings.
The APA’s attempt to “make amends” to BIPOCs makes it sound as if this kind of reform will somehow put the profession back on the rails. Sadly, the reality is very different. It is worth asking if making black psychiatrists feel “valued and seen” within the profession’s ranks, or lobbying for higher insurance reimbursement rates, will do anything substantial to change the historical trajectory of a medical field that has fallen short in so many other fundamental ways. Apologizing for psychiatry’s racism may sound rhetorically appealing in 2021, yet it does very little to improve Americans’ mental health.