During the early decades of the twentieth century, William Alanson White and the medical staff at St. Elizabeths Hospital in Washington, D.C. developed an ambitious program for U.S. psychiatry in which the profession would be dedicated to the reconstitution of mentally-fit and socially-productive American citizens. The racist assumptions beneath this program led most psychiatrists at the institution to expect little more than deference, dependence, and common labor from their black patients, preventing them from comprehending the impact of substandard and racially-segregated care. Black men and women were acutely aware of the injustices they faced. When they rejected elements of the hospital's medical regimen, these patients were also rejecting a social vision that consigned them to the margins of American civic life.
During the early decades of the twentieth century, American psychiatry underwent a profound transformation. Professional leaders began to look beyond the walls of the provincial asylum, formulating a model of human conduct in which shared values were interpreted through the lens of mental health and mental illness. The founding generation of asylum physicians in the mid-nineteenth century had viewed their work in highly religious terms. Twentieth-century psychiatrists, in contrast, sought to restore their patients to citizenship in a largely secular civic order whose dominant relations were among the individual, the family and the state. While the asylum remained the de facto base for the profession, physicians associated with what has been described as the "new psychiatry" also cultivated links with such institutions as the schools, the courts, and the military.2
The society in which American psychiatrists articulated this vision was shot through with inequalities, foremost among them the political and legal subjugation of black men and women. In this paper, I examine the impact of existing racial hierarchies on medical thought and patient care at a leading federal psychiatric facility of the period — St. Elizabeths Hospital in Washington, D.C. White physicians at St. Elizabeths tended to view their black patients as primitive, alien, and inferior, effectively situating them outside the bounds of American national identity. These assumptions led psychiatrists to expect little more than deference, dependence, and common labor from mentally ill black men and women, preventing them from comprehending the impact of substandard and racially-segregated care. Often black patients responded with justifiable suspicion and mistrust, a social posture that continued to shape relations with the psychiatric community well into the post-World War II era.
Originally founded in 1855 as the Government Hospital for the Insane, St. Elizabeths Hospital is among the most important psychiatric facilities in U.S. history.3 The institution is located just a short distance from some of the most noteworthy symbols of national culture — the White House, the U.S. Capitol, and the Washington Monument to name just a few — and it is difficult to imagine a city in which debates about civic identity might be more salient. St. Elizabeths' location in the mid-Atlantic region, moreover, makes it a useful corrective to accounts of psychiatric modernization that have focused exclusively on the Northeast.4 The institution has historically served both District residents and enlistees and veterans of the Armed Forces. Because most military patients were white, black men and women represented a relatively small proportion of the hospital's patients in the early decades of the twentieth century. Physicians nevertheless devoted an extraordinary amount of time and energy to the question of black mental illness.
Between 1903 and 1937, St. Elizabeths was administered by the eminent psychiatrist William Alanson White. Over the course of his tenure, White articulated an ambitious program for the profession and rose to a position of leadership in the field. Between 1910 and 1930, he developed an influential social evolutionary theory of mental health and illness. Drawing from the nineteenth-century sociologist Herbert Spencer and the philosopher Henri Bergson, White argued that all human conduct could be understood as the product of successively higher levels of integration. In this context, socially unacceptable behavior represented an inability to make an adequate psychological adjustment to a changing social environment. Institutionalized populations were to be understood as "social failures," men and women incapable of dealing with the complexities of life outside an institution.5
White identified mental health with a form of civilized rationality. He was an early and enthusiastic advocate of European psychoanalysis, championing the emerging work of Freud, Adler, and Jung well before they began to make serious inroads in American psychiatry in the 1920s. Yet White situated psychoanalytic insights in a framework resembling the genetic psychology of Clark University psychologist G. Stanley Hall. Hall had argued that the process of childhood development recapitulated the natural history of the human mind; the psychology of the child thus resembled the concrete and animistic thinking of "the savage." While Hall had only occasionally broached the topic of psychological impairment, White made it his central target, suggesting that the mechanisms involved in mental illness represented a reversion to immature, primitive patterns of thinking.6
White developed this framework as superintendent of a racially-segregated hospital in the nation's capital at a time when race relations were at one of their lowest points in American history.7 Most blacks in Washington, D.C. lived in dire poverty and were restricted to jobs in unskilled labor and domestic service. Washington also had a substantial black middle class, but most white residents continued to identify blacks with illiteracy and poverty.8 While White certainly shared the prejudices of his day, he does not appear to have ever explicitly theorized the racial inferiority of black Americans. In 1910 he spoke at Howard University's School of Medicine and invited students there to attend his clinical lectures alongside white students.9 It was only after officials from George Washington University expressed their opposition to integrated sessions that White introduced segregated instruction, assigning a member of his staff to cover the lectures for black students.10
Most of the physicians at St. Elizabeths, however, were not so broad-minded. The institution rapidly became a center for research in "comparative psychiatry." Much of this work was published in the Psychoanalytic Review, founded by White and his colleague Smith Ely Jelliffe in 1913. Though there was also an independent tradition of racist psychiatric theory upon which they could draw, physicians at St. Elizabeths frequently framed the issue in terms that could have come from White himself. When it came to dementia precox, a conceptual precursor of schizophrenia and the most common diagnosis among patients of both races, they argued that blacks' inferiority entailed a distinctive presentation of the disease. "During its years of savagery, the race had learned no lessons in emotional control, and what they attained during their few generations of slavery left them unstable," explained Arrah B. Evarts. "For this reason we find deterioration in the emotional sphere most often an early and a persistent manifestation."11 White physicians also maintained that depression was rare among blacks and that suicide was almost nonexistent.12 On the topic of an increase in general paresis (a form of neurosyphilis) among black patients, psychiatrists inevitably looked to blacks' licentiousness as an explanation.13
Doctors' views on the inherent depravity of blacks led them to dismiss the possibility of psychic conflicts between their sexual desires and the dictates of conventional morality. Given their limited cultural development, physicians reasoned, blacks lacked the inhibition responsible for so much distress in white patients. Physicians commented repeatedly on the absence of sexual symbolism in their black patients' illnesses.14 When they did offer psychoanalytic interpretations, psychiatrists at St. Elizabeths tended to focus on the perceived psychology of race relations. John Lind suggested that nearly all blacks were dissatisfied with the color of their skin and that this "color complex" was even more pronounced among the mentally ill, where it "very often moulds largely the topography of the delusionary field."15
Physicians at St. Elizabeths equivocated on the relative contributions of individual life-history and the cumulative weight of the racial past. Anthropologists identified contemporary indigenous groups with earlier stages of human development, so physicians combed ethnological accounts for insight into the racial unconscious. Lind linked the cosmology of West African tribes to the symptoms he observed in black men and women, discerning what he took to be evidence of "the savage heart beneath the civilized exterior."16 Evarts departed from her colleagues' emphasis on the historical racial unconscious, calling attention instead to the many folk beliefs that governed the daily lives of poor blacks. With the help of a lucid prisoner patient, Evarts documented a series of widespread practices that she felt might easily have been misattributed to past historical epochs.17
At times, physicians appeared cognizant of the social conditions behind their perceptions of racial inferiority. William Bevis condescendingly left open the possibility that even "[w]ith all the handicaps resulting from fears, low ideals, and primitive notions, it occasionally happens that the negro youth is fortunate in having the proper guidance to prevent him from making a complete wreck of his physical and mental life. … [M]any profit by the opportunities offered even in the South to secure a good education and develop into most excellent citizens."18
Bevis's caveat notwithstanding, most psychiatric observers viewed blacks as alien, inferior, and incapable of self-government. Even in the best of circumstances, they maintained, black Americans resembled children or savages rather than the sort of mature citizens needed to carry the nation forward.19 All of these traits were exaggerated in black mental illness. The lesson seemed inescapable: even in mental health, black Americans were a far cry from the sort of responsible and morally upright citizenry psychiatry sought to produce. Physicians at St. Elizabeths insisted that they based their conclusions on careful study and clinical experience. The records they maintained, however, reveal a far more complex portrait.
Most of the black men and women admitted to St. Elizabeths were from the District of Columbia or the surrounding counties in Maryland and Virginia. The District's commitment laws required that these men and women initially be taken to the Washington Asylum Hospital (later Gallinger Municipal Hospital), where they remained for several weeks before being transferred to St. Elizabeths if their symptoms did not abate. Occasionally an elderly black Civil War veteran was sent to the institution, and the number of black servicemen and veterans increased substantially after World War I.20
Family members were often instrumental in arranging the hospitalization of their mentally ill relatives. As was the case among white patients, this typically occurred in response to abrupt changes in personality or behavior that family members viewed as bizarre or irresponsible. The family of 29 year-old Irving Rawls reported in 1910 that he had started to "feel queer" about ten days before his admission. Soon he began talking about religion and attempted to break up the furniture in the family's home. When Rawls became so excited that his family had to restrain him, they decided to take him to the hospital.21 While black families appear to have tolerated unusual behavior for longer periods than white families, the proportion of black civil patients admitted to St. Elizabeths nevertheless often exceeded the percentage of black men and women in the community.22 This is not surprising given the dire economic circumstances most blacks in Washington, D.C. faced. Few had the resources to place their family members in a private facility; it is doubtful, moreover, that many such institutions in the region accepted black patients.
At times, patients offered their own reflections on the patterns of thought and behavior that brought them to the hospital. Like white patients during the same period, black men and women attributed the onset of their symptoms to a combination of biological and environmental factors, including physical exhaustion, a blow to the head, or overindulgence in alcohol. Six months after her admission, Bethany Jones sent a letter to her family. "I guess everyone really thought I was crazy," she explained. "I wouldn't talk to no one and when I did it was all nonsense and people didn't understand[.] … I was in a room to myself and I would sit and … I would curse and preach and make out that everybody was devils and there I was getting to be [a] real one myself[.]"23 Shortly after 59-year-old Julius Humphrey was admitted in 1915, his physicians made a transcription of his rambling and disconnected speech. Later, when the physician read the transcript back to him, Humphrey laughed and acknowledged that he might have spoken that way when he first arrived, having previously experienced similar episodes.24
Black patients often experienced their illnesses in terms that reveal the importance of race as a cultural category during the Jim Crow era. Both black and white patients with general paresis tended to express grandiose ideas. Black patients, however, often did so in terms which both recognized and implicitly subverted racial hierarchies. When he was admitted in 1910, 37 year-old musician Jacob Jeffries asserted that he was the "wisest coon in the world;" later he maintained that "the white world is living on his money."25 Robert Taylor told physicians in 1925 that he had "the prettiest brain of any man in the world — colored or white," and that he had killed a hundred members of the Ku Klux Klan.26 Elderly patients and those experiencing delusions of persecution often spoke in terms of a racialized social identity as well. Robert Cook was fond of giving orders to the nursing staff, insisting that "this is no longer slavery times, and you'll do as I say!"27 Seventy-two year-old Sally Jackson was plagued by voices that cursed her and called her "nigger." "Patient will often accuse some one of talking about her when they are not even saying a word to her," wrote an attendant in 1928. "Will say, 'I heard what you said. If I am a negro you are one, too, and if I get on you someone will have to pull me off because I will tear you to pieces.'"28
The language staff members employed in clinical assessments reflected an expectation that blacks ought to assume a deferential attitude in the presence of whites. Officials exhibited a casual and patronizing familiarity with their black patients, identifying them solely by their first names in a manner that rarely appeared in the records of white patients. Civility, politeness, and adherence to the social norms governing race relations intertwined seamlessly with evaluations of mental health. Physicians and employees described blacks in terms of their "obedience" long after abandoning such language in descriptions of white men and women, and while such perceived qualities as "rudeness," "arrogance," "surliness," "hatefulness," and "impudence" did not by themselves mark a black patient as ill, they did little to improve a physician's perception of a patient's prospects for recovery.
Clinical records thus confirm the existence of deeply racist assumptions among the staff at St. Elizabeths. In cases of dementia precox, "apathy" and "lack of initiative" loomed large among the symptoms reported for white men. Medical officials' views on the natural laziness of blacks, however, prevented them from recognizing similar changes in their black male patients.29 Conversely, when males became agitated or excited, physicians' and employees' belief that blacks lacked self-control sometimes led them to overestimate the dangerousness of the situation. Black men were occasionally transferred to Howard Hall (the hospital's highly-secured forensic division) merely on the suspicion of threatening behavior, while white patients avoided such reassignment even after becoming destructive or assaultive.30 And when civil patients improved enough to be considered for visits or discharge, social service workers subjected black families to intensive and disproportionate scrutiny.31
The responses of black men and women to their confinement varied widely. In a few instances, patients themselves sought admission; with time others grew comfortable at the hospital.32 Far more often, however, black patients resented their detention. Many experienced their lack of freedom as a form of unwarranted incarceration. "I call [this place] a prison," declared 37 year-old Abraham Tibbs in 1911. "Some say it ain't [but] all I can see is bricks and wood and wires and iron."33 Martha King interpreted her admission in similar terms; officials noted that she was carried into the hospital "squealing, squirming, and resisting." King was in the late stages of neurosyphilis, but when asked if she knew where she was her response was simple and direct: "Jail."34 Among patients confined for long periods, the daily routine could grow wearisome. When an attendant asked Jacob Jeffries if he knew the date, Jeffries replied that "every date is the same around here."35
By providing separate and inferior facilities for black patients, officials at St. Elizabeths legitimated and reinforced the prevailing racism of the era. The fact that St. Elizabeths was a federal institution was particularly important in this regard; the provision of qualitatively different services according to race gave the impression of federal sanction for racial discrimination.36 As the hospital grew, white patients generally moved into new and improved facilities while black patients were shifted to existing buildings. Perhaps the best evidence of inferior conditions comes from the era of desegregation, when the physician in charge of a division formerly occupied by black patients reported that "a number of the relatives of white patients transferred to West Lodge Service were quite disturbed … not so much because of the mixing of the races as because of the relatively poor physical facilities on the wards."37
Because they were typically housed in older buildings, black patients did not benefit as readily from innovations in treatment and architectural design. Hydrotherapy facilities were first installed in Oaks Building for white men in 1897, and further facilities were included in the new admission buildings for white men and women in 1903. The wards for black male patients, however, lacked even the most elementary equipment until 1926.38 Physicians relied on such techniques as the wet sheet pack and continuous bath to help calm agitated patients, and it is likely that the lack of hydrotherapy facilities contributed to the higher rates of restraint and seclusion on wards for black patients. Between 1919 and 1922, these incidents occurred with a 50 percent greater frequency among black males than among white male patients.39
Labor was an integral component of life for all patients at the hospital, but it occupied a particularly central place in the care of blacks. Men were typically assigned manual tasks, sometimes in work gangs overseen by white employees; women were employed primarily in the hospital's kitchen and laundry. Black patients were keenly aware of the contradictions involved in working without pay. Most were just one generation removed from the experience of slavery, and black men in particular recognized that ownership of one's labor was a crucial component of their freedom. Abraham Tibbs complained in 1910 that "[t]he onliest time I got good sense is when I'm working for nothing, but when I ask for pay like you would, then I am out of my mind and insane."40 The issue was particularly acute during hard economic times. After Edmond Payne left the hospital on convalescent leave in 1932, he returned for evaluation several times at the request of the medical staff before receiving his formal discharge. "He tells at length about the work he did in the dining room on Howard Hall," noted the physician during one of these visits, "and inquires whether or not he might receive some pay for this work[.]"41
The system of racial segregation encompassed intramural recreation as well. During the 1900s and 1910s, black patients appear to have occasionally participated alongside white patients in such activities as band concerts, movies, and carriage and automobile rides. Because the individual ward remained the basic unit of social organization, however, it is likely that most events remained segregated as a matter of fact if not of official policy. As the hospital's population grew, its recreational program was taken up by a chapter of the Red Cross, which first established a presence on the campus after World War I. The formal Red Cross program was strictly organized along racial lines. When chronically-ill black patients began to outnumber acutely-ill white ex-servicemen in their use of the Red Cross House, officials responded by limiting the hours during which the building was open to blacks.42
Confronted with inferior living facilities and a condescending medical staff, black men and women at St. Elizabeths often rejected elements of the hospital's medical regimen. Even more so than white patients, many black patients simply wanted to be left alone. Black women in particular turned to one another for support rather than relying on white nurses and attendants. When it came to their mental lives, patients were often more forthcoming with their peers than with the medical staff. This was particularly clear in the case of Harriet Cross, as recorded by her ward physician in 1920: "The nurse reported to me today that the patient has talked very freely to the other patients, evidently more freely than on examination, telling them that she was sent here on a mission from God[.]"43
Black patients also registered their dissatisfaction in more concrete ways. As was the case among white patients, it was not unusual for black men and women to refuse work, damage property, or even assault the staff. Some destroyed their clothing or bed linens in a form of inchoate protest, while others took any opportunity they could to escape. The threat of violence between blacks and whites carried particular meaning in the Jim Crow era. During a 1906 investigation of the hospital, a supervisor in Howard Hall described an incident involving a patient who believed that "the white people are very much opposed to the colored people and would oppress them in every way possible." One day in the dining room the patient "took a pitcher and struck one of the attendants over the head. They took him out of the dining room, and three or four colored men jumped up and said, 'Boys, stand by your color,' and they had a very serious time there for 15 or 20 minutes, perhaps, and it would have been more serious, perhaps, but for the assistance of some of the patients."44
Patient care at St. Elizabeths was thus marked by profound racial stratification. To be sure, white patients, too, found themselves living in a highly structured environment where they were regarded as somehow apart from the rest of American society. Black men and women, however, experienced a double form of marginalization, residing in a literal institutionalization of white authority. Though the label of insanity sometimes allowed inmates to challenge racial hierarchies, black patients were also more directly and more consistently under the surveillance of white officials than was the case on the outside. The fact that disparities in care at St. Elizabeths were part of a larger system of racial inequality did not make them any less damaging. Indeed, the symbolism of federal sanction for racially-stratified mental healthcare in the nation's capital made these injustices all the more pernicious.
In some respects, physicians at St. Elizabeths were merely rearticulating existing stereotypes in a new language. Blacks were viewed as atavistic and socially inadequate; their "primitive" psychological development was interesting primarily as a reminder of just how far the human race had progressed under the banner of American civilization. To the extent that psychiatric perspectives succeeded in shaping common sense assumptions of the era, however, these physicians helped to reinforce existing hierarchies. The new psychiatry could thus provide a novel mode of self-understanding for educated white Americans without fundamentally challenging the privileges they enjoyed.
While the stakes were high for all of the actors involved in this drama, the most direct consequences fell upon the black men and women admitted to St. Elizabeths. Throughout this period, most blacks in the nation's capital faced economic hardship and racial discrimination on a daily basis. When they broke down, they found little respite on the hospital's wards. Black patients were aware of the injustices they faced; when they rejected psychiatric authority, they were also rejecting a social vision that consigned them to the margins of American civic life. Recovery from mental illness was a difficult task under even the best of circumstances. The added burdens of an oppressive racial ideology could only have magnified the obstacles black patients faced in their struggles to regain their former lives.