This article appears in the December 2023 issue of The American Prospect magazine. Subscribe here.
In October 2022, Porter Burks, 20, was shot and killed by Detroit, Michigan, police. Burks suffered from paranoid schizophrenia, and his family had called the police out of concern for him. According to a wrongful death lawsuit filed by the family, the police said they would take Burks to a hospital once he was found. Instead, Burks was shot 19 times as he wielded a pocketknife in the middle of the street.
Burks’s story reminds the public of how ill-equipped the police are to deal with mental health crises, but it also reflects the dangerous intersection between criminal justice and race. When Black men have mental health crises, they are assumed to be a threat to others. Sometimes, they are armed or acting erratically; other times, they are just existing. In all cases, the Black man is facing a system that has made a myriad of assumptions about him before he ever actually encounters anyone or anything. Burks was up against that system as well.
Mentally ill people are more likely to be imprisoned, homeless, and victims of substance abuse. They also experience high rates of unemployment and general social isolation. But mental illness was once simply misunderstood, or ignored. There came a point at which criminalizing mental illness morphed into a useful tool of oppression, and Black men were often the scapegoats. There was a concerted effort to paint Black men as unstable, irrational, and paranoid, and sometimes outright “schizophrenic.”
Schizophrenia is a psychiatric condition that ails about 1 percent of the population. Theoretically, this should occur at the same rate among all racial and ethnic groups. Yet studies have continually suggested that Black men are diagnosed as schizophrenic at higher than average rates. There are also cases of misdiagnosis: A 2018 article in Bipolar Disorders found that Black people with bipolar disorder are more likely to be misdiagnosed as schizophrenic. The reasons for this are wide-ranging, but the medical community generally accepts that racism plays a part.
There came a point at which criminalizing mental illness morphed into a useful tool of oppression, and Black men were often the scapegoats.
Schizophrenia has an “association with lower socioeconomic status, with past trauma, and it may show that for Black people, there’s a greater prevalence or incidence of schizophrenia, but it’s not because they’re Black,” Stephen McLeod-Bryant, president-elect of Black Psychiatrists of America, told the Prospect. “It’s because they live in environments that are prone to stress and trauma that may trigger psychotic disorders.”
A limited cultural understanding of the disease leads to people presuming that those with schizophrenia are unstable members of society who should be treated with caution. The diagnosis has lasting effects on a person’s life, how others see them, and how they see themselves. It came to be strongly associated with Black men in the 1960s, and has prevailed through the decades. It feeds into society’s larger perception of Black men as violent.
None of this discounts the pain that Black men like Burks and others suffer because of schizophrenia and psychosis. Still, encounters by Black men with the police are always reflecting these stereotypes, contributing to miscommunication and, thanks to our militarized criminal justice apparatus, to swift escalation and death.
“There is a cultural misperception in the Western world in which the Black man is demonized, consciously and unconsciously, to be a threat,” McLeod-Bryant said.
So many Black men who need help do not get it because of this perception, and others are shot and even murdered over it. It is not an association that will be broken lightly, but understanding where that gut reaction comes from can be a start.
HOW ANY ILLNESS OR DIAGNOSIS IS UNDERSTOOD today only comes from decades of trial and error by medical professionals. However, the boundaries of this trial and error are dictated by not just the medical standards at the time, but also the social circumstances in which it takes place.
As Jonathan Metzl argues in his 2010 book The Protest Psychosis: How Schizophrenia Became a Black Disease, schizophrenia was not spared from this fate. Ultimately, there was a marked shift in everything from the language used to describe and diagnose to the race of the patients admitted for the ailment, and it occurred just as the civil rights movement made headway. It soon became an easy way for the state to justify locking up Black men as they fought for their freedoms.
At that point, the typical “schizophrenic” patient, from the viewpoint of the profession, changed from a docile, confused white woman to an angry, violent, delusional Black man. “Official descriptors emphasized the generally calm nature of such persons in ways that encouraged associations with middle-class housewives,” Metzl wrote about the definition prior to the 1960s. “In 1968, in the midst of a political climate marked by profound protest and social unrest, psychiatry published the second edition of the Diagnostic and Statistical Manual (DSM). That text recast the paranoid subtype of schizophrenia as a disorder of masculinized belligerence. ‘The patient’s attitude is frequently hostile and aggressive,’ the DSM-II claimed, ‘and his behavior tends to be consistent with his delusions.’”
In other words, the rendering of a clinical, supposedly scientific diagnosis was not immune to the changing culture. “I can’t say that it was exactly causal,” Metzl told the Prospect. Still, “it was reflective of white anxieties of the moment.”
KEN BLAZE/AP PHOTO
A protester holds up a picture of Tamir Rice, a 12-year-old boy murdered by Cleveland police in 2014.
Today, schizophrenia is understood as a person’s disordered thinking severely affecting their quality of life. Often, this state of delusion is called psychosis. Psychosis, however, can be an aspect of many mental illnesses—from trauma to depression—and does not itself constitute schizophrenia. The DSM-5, the latest edition of the prevailing diagnostic handbook, requires a person to be in that state for six or more months to be eligible for a schizophrenia diagnosis. Also, people with schizophrenia are more likely to be victims of violence than perpetrators of it.
Metzl’s work aims to “show how there is implicit bias. It’s not just about the prescriber, but about the actual diagnostic category.”
In 2021, the American Psychiatric Association (APA), publisher of the DSM, acknowledged this bias and the harm it has done. The organization issued an apology, stating, “Late 20th century psychiatrists commonly attributed their minority patients’ frustrations to schizophrenia, while categorizing similar behaviors as ‘neuroticism’ in white patients.” The organization also acknowledged how APA members have played a role, and they conclude: “This reveals the basis for embedded discrimination within psychiatry that has contributed to reduced quality of care for BIPOC populations and perpetuation of dangerous stereotypes.”
This is one way racism becomes written into systems. It is rarely explicit, and sometimes only visible with decades of perspective in between. That does not mean it was never there.
TAMIR RICE WAS MURDERED BY CLEVELAND, OHIO, POLICE in 2014. Rice, 12, was on a playground playing with a toy gun when police forces descended upon him and shot him. Nearly a decade later, the case stands out. People at the time were shocked by the police’s overreaction, and their quickness to shoot. Many noted Rice’s young age, how he was unarmed, and the police’s later attempts to paint Rice as a threat, using the toy gun as justification.
Rice was not the first or last Black child to be murdered by the police. But the toy gun somehow complicated the story. In the most official telling, police were unable to distinguish the toy gun from a real one, and were acting on the authority that there was a threat nearby. This argument—which was used to decline to indict the officer involved—neglects how the 911 caller had specified the weapon in question was “probably fake,” and that the brandisher was “probably a juvenile.” The police car was still moving when the officer fired the first shot at Rice.
At least some of the work to undo implicit bias has to start with psychiatrists in the field.
There were no attempts to assess the full situation, to de-escalate, or to take accountability after the fact. All there was in the moments before Rice was shot was a perceived threat, and the association of Black people with violence and aggression.
It may seem clear now that the responding police officer was acting out of some sort of bias. Removing this bias is the partial aim of options like community alternatives to policing. But dismantling implicit bias goes beyond one institution, even beyond criminal justice.
As we see with the changing diagnoses of schizophrenia, psychiatric institutions have played a role in forming the particular type of implicit bias that leads cops to shoot a 12-year-old boy with a toy gun. At least some of the work to undo bias has to start with psychiatrists in the field.
ONYI OKEKE IS A BOARD-CERTIFIED PSYCHIATRIST who focuses on schizophrenia in the Black community, specializing in the diagnoses in young Black people. Okeke understands the harm in making evidence-free assumptions about a patient.
“There is a lack of agency in terms of treatment of psychosis,” Okeke told the Prospect. Too often, Okeke said, physicians do not stop and empathize with a patient, or take the time to fully explain a diagnosis and potential treatment, so the patient can make an informed decision. As a physician herself, Okeke tries to consider the whole history and state of a patient, looking past their diagnosis alone.
“If somebody, especially as a Black person, [presents] with psychotic symptoms, very heavy-handed drugs, like antipsychotics, are often used,” Okeke said. “But there is a whole nuanced way to do it.” Okeke’s approach involves considering the patient’s past encounters with the mental health system, and for the Black men she works with, the ways racism may have been subtly or overtly a part of the process.
“From a historical standpoint, race impacts medical communication because racial tensions are structured into clinical interactions long before doctors or patients enter the examination room,” Metzl wrote in 2010.
Part of the problem is a lack of Black psychiatrists. As of 2021, APA data showed that just 2 percent of psychiatrists in America were Black. This cultural understanding can be very important for a healthy medical relationship, but McLeod-Bryant points out how systemic racism impedes Black doctors. And as Okeke cautions, being a Black doctor does not automatically make them fully understand a Black patient.
“Even with that I still have to have humility,” Okeke said. “I educate myself as much as possible because my own experiences with racism have been different. [I] still have to put their story at the forefront.”
Without seeing and understanding the wound that racism creates, one may be inclined to dismiss racial tension as an overreaction. And an overreaction can be seen as “crazy.” But with a full view of the history of the patient and the culture they are subjected to, psychiatrists may be more empathetic in their diagnoses; and maybe the police can be more careful in their response to a crisis.
