This book takes a fascinating and unique approach to illustrating how psychiatry and the general public misused the diagnosis of schizophrenia as a label to portray African Americans who fought for civil rights as having severe psychopathology.

Beginning with this absurd-sounding assertion, Dr. Metzl presents a retrospective, longitudinal study of the pattern of pre- and post-civil rights-era diagnoses at Ionia State Hospital in Michigan that clearly shows the changes in associations between race, schizophrenia, and violence over time. Using case histories collected before the civil rights movement, when psychiatry and the public assumed that patients with schizophrenia were white and harmless, the author shows how the diagnosis came to symbolize a disorder primarily of African-American men and characterized by paranoia and dangerousness. He makes compelling arguments that this shift in schizophrenia occurred as a result of research articles in leading psychiatric journals that provided “proof” that African-American men with schizophrenia were violent. His evidence is a review of 300 research articles from 1950 to 1980 revealing that “research articles in leading psychiatric journals preferentially applied language connoting aggression and hostility to African-Americans during the 1960's and 1970's”. He highlights Bromberg and Simon's (1) article on “protest psychosis,” which linked the Black Power movement to literally causing delusions, hallucinations, and violent projections among black men.

In addition, he provides a review of mainstream journalism and illustrates that the frequency of association between the terms “Negro” and “schizophrenia” increased from the period 1930–1955 to 1956–1979 and that the media furthered the misapplication of the diagnosis of schizophrenia to black males in the civil rights struggle. His review also examines the misinterpreted “split personality” concept that dominated the American public's perception of the nature of schizophrenia, with the word “schizophrenia” often used to characterize the normal psychological functions of ambivalence or conflicts within life. Ergo, as African Americans had to live in two worlds—a black one and a white one—they were hypothesized to be prone to schizophrenia.

African Americans were at least four times more likely than whites to receive a diagnosis of schizophrenia. Recounting the history of how, in 1977, Ionia State Hospital transformed from a mental hospital to a correctional facility, Metzl illustrates how fear of “psychotic” blacks shifted the social service infrastructure from hospitalizing schizophrenia patients to incarcerating them. Accordingly, people diagnosed as having schizophrenia reside more often in penal institutions than in psychiatric hospitals, and the rate of schizophrenia in prisons is five times higher than the rate in the general population. Psychiatry positioned itself as an authority that interpreted the crisis posed by angry, protesting black men during the civil rights era, resulting in a seemingly benevolent social institution's dominating, oppressing, and exploiting people of color.

Metzl suggests that poorly taught cultural competence gives people the false notion that their professional training helps them be culturally sensitive. Unfortunately, race-based misdiagnosis distorts the objective use of diagnostic criteria, so psychiatry must teach doctors to assess people of color objectively. Finally, he recommends that psychiatry step away from economic dependence on pharmaceutical companies and be more thoughtful about how cultural forces influence diagnostic categorization.

The reviewer reports no competing interests.