Opinion: Micha Frazer-Carroll
Therapy Today, October 2023

One morning in the summer of 2016, my mind split in half. As I opened my eyes to bring the day into focus, the same way I had done every single day of my life so far, I couldn’t quite make things sharp enough. It was as if I hadn’t fully awoken to ‘reality’ but was stuck in some liminal purgatory between the dreaming and waking worlds.

Everything looked as if it was taking place on a television screen – myself, an audience member watching my own life play out from afar. As the days, weeks and months dragged on, I couldn’t shake this dizzy, detached and anxious feeling, and began to spiral into panic attacks multiple times a day. I found myself in a living nightmare, feeling not quite dead but not alive either, resigned to the idea that I would either have to relinquish life or accept this new waking death 

This experience, which lifted after a number of months, was in retrospect one of the most destabilising yet significant periods of my life. It was a time in which I went mad. There is a clinical name for what I was experiencing: ‘depersonalisation disorder’, a state of ‘dissociation’ that is linked to extreme anxiety levels. People who experience depersonalisation for a long period, like I did, often express relief on this realisation that they have not ‘gone mad’. But to me, it was undoubtedly madness; I could feel it in my mind and I could see it in the way that people ooked at me when I tried to explain my predicament. Lacking a strong community around me, and conscious of my ‘unpalatable’ form of distress, I intuitively swallowed my madness. I only dared to utter it in interactions with various professionals, while treading precariously around the scripted questions that determine whether a person will be sectioned.

For so many others like myself, madness and mental distress are overwhelmingly isolating endeavours under our current conditions. They can cut us off from our communities, make us feel trapped, take over our lives and see us further secluded within the system – both physically and metaphorically. They can pile on shame, disgust and trauma, turning our days into a struggle to simply stay alive.

It is only years following my experience of depersonalisation that I can look back and see that it was connected to intergenerational trauma, racism, ableism, abuse, work and my lack of a caring community.

Social and political

Black Caribbean people living in the UK are disproportionately likely to be diagnosed with schizophrenia, with one seminal study in 2006 finding that we are nine times more likely to receive this diagnosis than our white counterparts.¹ Notably, this extremely high rate of diagnosis in the UK has not been replicated in the Caribbean – suggesting that these rates are more to do with the social and political experiences of black British people.²

Since the experiences described as schizophrenia are often thought to be linked to stress and trauma, these rates of diagnosis might be considered entirely representative of our lived realities. I grew up hearing stories of my Antiguan grandmother being invited to board a ship to England, only to be chased down the street by violent white nationalists when she stepped onto its hostile shores. Living in contemporary Britain continues to be traumatising for many people of colour, with racism embedded in each of its institutions.

However, in understanding the disproportionate rate of schizophrenia diagnoses, it is also necessary to interrogate the racism that is embedded in the foundations of psychiatry. Racism is intimately tied to the history of psychiatric diagnosis; most famously, the American physician Samuel A Cartwright proposed the diagnosis of ‘drapetomania’ in 1851 to describe black enslaved people who fled from plantations.³ The schizophrenia diagnosis, which originates from a 19th-century diagnosis called ‘dementia praecox’, has a similarly racialised history. Psychiatrists influenced by eugenics saw dementia praecox as associated with black ‘degeneracy’ and ‘primitiveness’.⁴ The British colonial psychiatrist HL Gordon, who worked in a Kenyan mental hospital in the 1930s, even suggested that African people developed the disorder due to the ‘inferior durability’ of their brain cells.⁵

After a brief period of its usage as a ‘housewife’s disease’ in the mid-20th century, schizophrenia was once again subtly naturalised as a black illness in the late 1960s.⁶ When DSM-II was released in 1968, the diagnostic criteria described schizophrenia as making people ‘hostile’ and ‘aggressive’ – attributes that overlap with stereotypes of black violence and criminality. During this period, black people in the US and Britain were increasingly diagnosed with schizophrenia.⁷ The systematic diagnosis of schizophrenia among black people was further used to pathologise their direct and organised responses to systemic racism.

Protest diagnosis

In the 1960s the US psychiatrists Walter Bromberg and Franck Simon suggested that Malcolm X and the civil rights movement had sparked a wave of violent schizophrenic symptoms and paranoid ‘racial antagonism’ in black Americans.⁶ As more black people joined the movement and consciously dissented against the racist societal order, Bromberg and Simon dubbed this phenomenon ‘the protest psychosis’.⁶ The ongoing association between schizophrenia, violence and criminality undoubtedly still plays a role in the disproportionate number of black people who are diagnosed. Black men, in particular, who experience mass criminalisation by the state, are now 10 times more likely to receive a diagnosis of a psychotic disorder than their white counterparts.⁸

Racism also factors into how the world responds to black people’s genuine mental distress. Since psychiatry has largely located black people’s distress inside of their bodyminds rather than in their environments, Caribbean Britons have historically been disproportionately subject to risky and invasive physical interventions like electroconvulsive therapy and major tranquillisers rather than more socially oriented approaches like psychotherapy.^8,9 Most of these issues persist into the present day, as black people are still nearly five times as likely to be detained under the Mental Health Act than their white counterparts. They are also more likely to make contact with mental health services through the police and criminal justice system, less likely to gain access to psychological therapies, disproportionately likely to be on a medium or high secure ward, and also more likely to be secluded and restrained on wards.⁸ Black distress is interpreted through the psychiatric gaze as irrational, dangerous and primal – something to be dominated rather than understood.

Even in the therapy room, people of colour – who frequently only have access to white therapists – often report facing covert or overt racism. In 2017 I worked with students of colour to compile a report on their experiences in therapy. In a survey of 143 students and alumni, a significant number of people said that white therapists had stereotyped them, adopted culturally inappropriate lines of questioning, or questioned whether their experiences of racism were really ‘real’.¹⁰ The most common concern students raised was that they had to spend a large amount of session time simply explaining basic elements of racism or their culture. As we organised around these concerns, other students and I also found ourselves struggling with a therapeutic institution that saw itself as neutral and apolitical. Ultimately, many students found that the only forums equipped to hold their experiences were explicitly political consciousness-raising groups and peer support spaces. We came to learn that, while the therapy room can be a place of support and healing, it can also reproduce racial violence through to unequal power dynamics and the desire for individualism and ‘objectivity’.

Psychiatric imperialism

I have seen the harms of ‘psychiatric imperialism’ in my own community in Britain. In many African and Caribbean cultures, the ‘symptoms’ associated with schizophrenia diagnoses are not understood as pathological but rather as having particular spiritual meanings. My mother grew up in the Pentecostal Church, in which churchgoers were encouraged to ‘get in the spirit’, shake, laugh, shout, dance, speak ‘in tongues’ and communicate with the voice of God. According to the psychiatric standard in Britain, these were signs of schizophrenia, and saw my family members pathologised. The impact of this was the control of racialised people and their various ways of making meaning in the world

The national and global suffering that we see in the form of mental health statistics cannot be viewed in a political vacuum. The world makes us mad, and then goes on to define who is pathologised as mad, and how they are treated. The issues I have covered are by no means an exhaustive list, but they are particularly clear examples that speak to the social contours of the mental health crisis. We should also remember that these systems are not really separate at all – they are interlocked and reinforce one another. Most people are impacted by more than one system.

As the poet Audre Lorde has written, we do not live single-issue lives.¹¹