Abstract
Martin Summers has written an excellent history of Saint Elizabeths Hospital and its relationship to Washington DC’s African-American community. Summers charts changes in personnel, policy, funding and treatment regimens, while also documenting the persistence of racial bias in patients’ experiences and in psychiatrists’ conceptual frameworks. This is not, however, a tale of abuse and indifference, as Summers emphasizes the agency of African-American patients and their advocates. He also distinguishes racism from medical malfeasance in analysing the actions and beliefs of white physicians. The result is a nuanced, comprehensive examination of race and US mental health care.
The first two chapters discuss the 1855 founding of Saint Elizabeths. Because it was a federal institution, it was often held up as a national model. Although it was neither the first nor the only institution to accept African Americans, Summers argues convincingly that the racial segregation embedded in its design ‘privileged the white patient while it also worked to construct the white psyche as the norm’ (p. 34). In making this point, however, Summers misconstrues the history of the Eastern Lunatic Asylum of Virginia. He writes that John M. Galt, Superintendent of the Virginia asylum, was a proponent of segregated wards whose opinions were emulated by the Superintendent of Saint Elizabeths, Charles Nichols, but the influence actually operated in reverse. Similarly, the assertion that ‘no superintendent, including Nichols, contemplated hiring African American attendants’ is belied by Galt’s example, as he employed enslaved attendants (p. 60).
Chapters 3 and 4 examine the rapid growth of the hospital from 1877 to 1900, a period in which a ‘particularly racialized concept of black insanity’ (p. 70) emerged under the superintendence of William Whitney Godding. Fuelled by the spurious eugenic theory of degeneration and the increasing numbers of patients entering state facilities, many physicians portrayed African Americans as developmentally too primitive to handle emancipation and uniquely prone to mania. To maintain segregation, African Americans were grouped together regardless of diagnostic classification, with work assignments also varying by race. Outside correspondence reveals that patients and their families countered these constraints, attempting to collaborate with doctors or challenge their authority. Although the letters constitute individual responses rather than a movement against racial inequities, Summers demonstrates that black Washingtonians regarded Saint Elizabeths as ‘an arm of the federal government’ and themselves as citizens entitled to healthcare (p. 120).
Racial disparities and patient agency are explored further in four standout chapters covering 1903–55. Chapter 5 focuses on Superintendent William Alanson White’s tenure, during which Saint Elizabeths became ‘a model teaching and research hospital’ (p. 126). Dr White’s clinical staff was especially keen to situate itself at the forefront of comparative psychology. They published prolifically, but their publications mainly recast older racial stereotypes for modern audiences. Summers shows that clinicians’ refusal to see African Americans as individuals led them to hold fast to the notion of a ‘distinctive black psyche’, even though ‘the empirical data failed to support their theoretical premises’ (p. 128).
African-American patients were more than mere ‘objects of medical scrutiny’ (p. 155). Parsing annual reports and case records with exemplary sensitivity, Chapter 6 looks at the ways in which racialist assumptions and gender expectations shaped patients’ involvement with different therapies. For example, Summers observes that women were more likely than men to be treated with hydrotherapy, and that African-American men did not have access to therapeutic tubs at all. Laundry and kitchen labour, however, continued to be assigned exclusively to African Americans, although patients questioned labour’s therapeutic value and demanded compensation. Unfortunately, resistance sometimes provoked punitive responses, with black women disproportionately subjected to restraints and seclusion. Other challenges arose from the cultural incompetency of white clinicians who did not distinguish psychosis from the belief in conjure and ‘alternative medical epistemologies’ to which some black patients subscribed (p. 177).
Chapters 7 and 8 consider reform at the hospital. The Progressive Era saw the broadening of community care programmes associated with the mental hygiene movement. There were limited collaborations with local partners such as Howard University, but the fortifying of segregation in the capital imposed boundaries. Several developments helped activists to overcome these boundaries and eventually end segregation. In 1946, the US Army and Navy began to send service members to Veterans Administration hospitals. Consequently, the admission of black civilians to Saint Elizabeths grew at the same moment that more white Washingtonians were moving to the suburbs. Civil rights and black professional organizations effectively drew attention to the hypocrisy of segregation and discriminatory hiring practices at a federal facility ‘in the capital of a nation that sought to project a self-image as a beacon of freedom and equality’ (p. 235), leading to the hospital’s gradual integration in the 1950s.
The last two chapters deal with the aftermath of integration and de-institutionalization. While Chapter 9 shows that clinicians abandoned the ‘black psyche’ in favour of a universalist approach, the inaccessibility of patient records renders it impossible to know whether psychotropic drugs were disproportionately given to African Americans. What is certain is that ‘by 1955 the institution’s best days were behind it’ (p. 276). The final chapter delves into the vicissitudes of de-institutionalization, especially the loss of funding in the 1970s and 1980s that turned the hospital into an ‘emblem of federal neglect’ (p. 308).
Madness in the City of Magnificent Intentions is a dense book that tells a complex story with acuity. Throughout, Summers toggles between the racialist theories that shaped the design and operation of Saint Elizabeths, and race as it was experienced by African Americans who lived in and near the institution. There are few asylum histories that grapple with race as thoroughly and thoughtfully as this one does, making it essential reading for historians of psychiatry. General readers who want to understand how and why disparities have undermined the treatment of the mentally ill in the USA will also be richly rewarded.