Can Racism Ever Be Treated With Antipsychotic Medication?

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When I lecture about conspiracy theories and the potential harms of firmly held ideological beliefs,¹ one of the most frequent questions I’m asked is whether such beliefs can be treated psychiatrically, whether by psychotherapy or medications.

I have several responses. One is that, generally speaking, we should avoid modeling ideological beliefs—whether they’re conspiratorial, political, or religious in nature—as pathological psychiatric symptoms. More often than not, such beliefs are not the product of a disordered mind as they're a social phenomenon whereby such attitudes and positions are learned and adopted from others. Conflating such beliefs with delusions therefore runs contrary to the DSM-5 specific exclusion of shared cultural or subcultural beliefs from the definition of delusion. In other words, delusions aren’t just things that we come to believe because other people tell us they’re true.

As to whether or not ideological beliefs—regardless of their pathology—might be amenable to psychotherapeutic interventions, my answer is that, in keeping with the joke that asks how many psychiatrists it takes to change a lightbulb, the “lightbulb” has to really want to change. If someone is open to modifying their ideological beliefs and wants to do so, interventions like cognitive behavioral or psychodynamic therapy could help. But attempting such interventions in someone uninterested in change would probably go nowhere fast or, as so often happens outside of psychotherapy, descend into argumentation.

Finally, with regard to whether psychiatric medications might be able to temper ideological beliefs, there’s no convincing evidence to support that this would be so. Although it might be an interesting study, there aren’t any randomized, controlled trials of antipsychotic medications for conspiracy theory beliefs. But I wouldn’t expect an antipsychotic medication to decrease belief in conspiracy theories any more than I would expect them to decrease religious or political beliefs.

Is Racism a Mental Illness?

Back in July, however, a case report by Arif et al. published in the Psychiatric Times concluded otherwise after describing a patient with racist beliefs that were indeed modeled as a symptom of psychosis and successfully treated with antipsychotic medication.¹

The idea that racism could, in some instances, represent psychosis or delusional thinking isn’t new. Back in 1969, in the midst of the Civil Rights era’s social unrest, a group of Black psychiatrists including Harvard University Professor Alvin Poussaint proposed just that. Although the recommendation wasn’t adopted by the American Psychiatric Association (APA), Poussaint has continued to make the case through the years. In 2002, he wrote that excluding racism from the DSM “leads psychiatrists to think that it cannot and should not be treated in their patients.”² He added:

To continue perceiving extreme racism as normative and not pathologic is to lend it legitimacy. Clearly anyone who scapegoats a whole group of people and seeks to eliminate them to resolve his or her internal conflicts meets criteria for a delusional disorder, a major psychiatric illness.³

In 2004, University of Illinois at Chicago psychiatrist Carl Bell, took that conclusion one step further, noting that “if some types of racism are found to be a mental illness or a symptom of a mental illness, developers of the next DSM should consider including other extreme prejudices, such as sexism, ageism, and heterosexism.”⁴

I disagree with the wisdom of such suggestions, largely for the same reasons that the APA rejected Pouissant’s proposal in 1969. Racism is most likely rooted in evolutionarily favored tendencies to “other” those who look different than us and is too structurally embedded and far too common among individuals—whether in its explicit conscious form or in the form of unconscious implicit bias—to warrant a label of mental illness.

This is not to say that racism should be dismissed as normal, that it isn’t a social blight, or that both structural racism and individual racist attitudes don’t lead to harmful discrimination and sometimes violent behavior—it is and they do. But as Bell suggests, the same could be said for misogyny and its role in intimate partner violence or rape. In part due to past errors in portraying homosexuality as a mental illness, the DSM has long advised against conflating mere social deviance with mental disorder,⁵ but separating the two doesn’t mean that a deviant behavior that causes harm should necessarily be condoned and shouldn’t be a target of intervention. For example, robbing banks and killing people are socially deviant and morally unacceptable behaviors that might be motivated by beliefs related to greed, jealousy, or revenge, but they deserve to be distinguished from mental illness and might not benefit from being "medicalized" by psychiatry. Modeling attitudes like racism as a symptom of mental illness could also have unintended consequences that include removing the moral responsibility of “owning” racist attitudes or mitigating culpability for violent behavior motivated by racism.⁶

Racism vs. Racist Delusions

That said, psychosis does sometimes overlap with delusional thinking. I once treated a woman similar to the one described in the Psychiatric Times case report. She expressed offensive racist beliefs about African American men—including peers and staff—that were rooted in paranoid delusions that she was being leered at and even raped by them outside the hospital as well as on the inpatient unit. This abated with antipsychotic medication so that she retracted her claims (with no known history of sexual assault) and was apologetic to the point of tears by the time of discharge.

In her case, however, I wouldn’t say that I was treating her racism so much as paranoid delusions that happened to have a racist theme. The delusionality of her beliefs was readily identifiable by self-referential paranoia based on subjective experiences that weren't reality-based—that is, they weren’t just racist attitudes about Black men out in the world, but false beliefs about what Black men were doing to her in the hospital.⁷

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That self-referential component was less clear in Arif et al.’s patient since the underlying rationale wasn't detailed. However, as she improved, she described feeling as if racial groups were "responsible for causing her mental and emotional abuse" in the setting of her recently losing a job. In any case, a diagnosis of schizophrenia was nonetheless suspected based on other accompanying negative symptoms such as social withdrawal and a “blunted affect” as well as patently false beliefs about the racial identity of her own family members. In reviewing the sparse literature on attempted treatment of racist beliefs, the authors conceded that newer onset beliefs like those of their patient are more likely to be modifiable than more entrenched beliefs.

Still, cases like Arif et al’s and mine, with relatively sudden onset of racist beliefs in those without overt longstanding racism do suggest the possibility that racist attitudes, like paranoia, could arise not only from life experiences and social dynamics but acute alterations in biological processes. As such, they open the door to the possibility that medications used to treat delusional thinking could, in some cases, also help with other types of entrenched ideological beliefs. As I mentioned earlier, putting that to the test of a clinical trial would be interesting, to say the least.