Aparttime: African American History Month and behavioral health

February has been known as National African American History Month (or Black History Month) since 1976 in the USA. The original goal was to educate about African Americans’ culture and achievements. Certainly, the Presidency of Barack Obama is an obvious example of that. Despite some controversy over whether it remains necessary or relevant, it continues this year with a myriad of educational activities across the nation.

Over time, each year had a theme. For 2012, the theme is “Black Women in America: Culture and History”. This theme dovetails nicely with the celebration of Women’s History Month in March.

As far as I know, our field of behavioral health has not paid much attention, if any, to this focus in February. If we did, we could focus on our advances in becoming more culturally competent in our care over the last couple of decades. Although, at least in my field of psychiatry, we have not yet elected an organizational president, there are more African American psychiatrists.

But perhaps more important than celebrating these advances is to educate and remind ourselves of what has still not been achieved in the behavioral healthcare of African Americans. For that, we can go back to slavery and see a theme that has persisted, even if it has changed in appearance and place. I would coin that as “Aparttime”, for its emotional resonance to apartheid and its cognitive implications of being apart.

If we start in the time of slavery, “Drapetomania” was an accepted diagnosis that emerged in 1851 to describe a kind of flight from home madness when slaves tried to flee captivity. Though it never made any of our modern DSMs, diagnostic discrimination has been present in our times. Research in the 1980s indicated the overdiagnosis of Schizophrenia (especially the Paranoid subtype) and underdiagnosis of Bipolar Disorder in young African American males. Before the days of managed care, hospitalizations were longer and commitments more common for this situation. For any mental health disorder, African Americans tended to receive more medication and less psychotherapy. Although these particular discrepancies have been reduced over the last couple of decades, they are not gone.

In a recent review of this problem, the psychiatrist Jonathan Metzl (who also has a Ph.D in American Studies) wrote a book published in 2010 called the Protest Psychosis: How Schizophrenia Became a Black Disease. He focused on the 1960s in Ionia State Hospital in Michigan, where he found a tendency to diagnose African Americans with Schizophrenia due to their civil rights ideas. He felt that this misdiagnosis was aided by a change in wording in DSM III, when “hostility” and “aggression” were added as signs of the disorder. Dr. Metzl concluded that this change produced a kind of structural racism.

Of course, we are now up to producing DSM 5 and those terms were done in DSM IV. However, this structural racism may be relocated in our current times. Now, instead of psychiatric hospitals, young African American males are located in a different place.

Ionia State Hospital is now a prison. And, with some fitting irony and tragedy, it is in prisons where behavioral healthcare discrimination can be most obviously found, that is, if anyone cares to look there. For a certain segment of the African American population, we have gone from the visible imprisonment of slavery  to the more invisible prisons.

When I started to work in a Wisconsin men’s medium security prison 3 years ago, it was obvious that young African American males, especially from the inner city of Milwaukee, were overrepresented. Not only that, but instead of the Paranoid Schizophrenia that was often diagnosed in our public clinics in the past, here the ubiquitous diagnosis was Sociopathic Personality Disorder, which of course is untreatable. Granted, there was often more than one diagnosis, but Sociopathic Personality Disorder was often the primary one in the patients that were transferred to me. Fortunately, I found that if you could build trust and an alliance, they might share the painful, shameful, and humiliating abuse suffered over their lives, which might then lead you to a Posttraumatic Stress Disorder diagnosis and real treatment options.

The statistics are quite sobering. Although our nation’s imprisonment rate has skyrocketed, in part due to the fact that our prisons now contain significant numbers of those with mental illness and substance abuse, the racial disparities are even worse. For example, African American males are nine times more likely than Caucasians to serve prison sentences for similar substance-abuse related crimes. Some now call this massive incarceration of young black males the civil rights issue of our time. I call it "aparttime."