Who decides what "insane" means? This was the major question of Ken Kesey's countercultural classic "One Flew Over the Cuckoo's Nest," which illustrated how mental illness could be deployed by the establishment to crush the individual. But a recent book by University of Michigan psychiatry professor Jonathan Metzl suggests that Kesey's novel might not have been far from non-fiction. In "The Protest Psychosis: How Schizophrenia Became a Black Disease", Metzl documents the shifting interpretations of schizophrenia through the 20th century, tracing its evolution from a "white middle-class woman's disease" to an "African-American man's disease." Specifically, with the political upheaval of the civil rights movement, popular culture began to associate angry black men with schizophrenia, which in turn influenced the way doctors interpreted and diagnosed the illness.
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"In particularly the early 1920s, 1930s, 1940s when the idea of schizophrenia itself was first coming to the United States from Europe there was a general assumption that persons who suffered from schizophrenia were either shy or calm or they were geniuses," Metzl says. "It was often represented as an illness that afflicted white novelists or poets and as I say, these were very often in popular and psychiatric representation assumed to be white people." But during the massive societal upheavals in the middle of century, ideas of sanity and insanity took on new meaning. "All of a sudden in the 1960s, American culture, newspapers, magazines, movies start to represent angry African-American men as in part being inflicted with a new form of this particular illness," and this change in popular perception of the disease directly influenced the clinical definition of it, Metzl argues. "All of a sudden in 1968, the second version of the Diagnostic Manual comes out and there is new language that says 'aggression, hostility, projection.'" The image of a schizophrenic person was all of a sudden more violent and unstable than the schizophrenic of 20 years before.

The practical consequences of this popular-cum-clinical shift in perception was that in the 1960s far more African-American men were institutionalized in psychiatric wards with schizophrenia. "Some had committed crimes, some had participated in civil rights protests, some had been participants in urban riots at the time. They all passed through various forms of the penal system and ended up diagnosed with schizophrenia and locked in the psychiatric wards," says Metzl. But were these men really schizophrenic? Or were they victims of shifting clinical definitions of disease, one that was prone to metaphoric interpretation?