Hidden Histories: Racial Injustice at St. Elizabeths Mental Hospital

Hidden Histories: Racial Injustice at St. Elizabeths Mental Hospital


Dr. Summers: I came across one woman who was admitted in I believe, 1866 her name was Lutetia B. And she was diagnosed with some form of mania. But in the column for supposed cause, was written, “The blackness of her husband.” Seeing that, “the blackness of her husband” listed as a supposed cause for the disease really, I think I probably pushed back into my chair.

Dr. Gordon: A decade before the end of slavery, Washington D.C.’s St. Elizabeths Hospital began treating Black patients for mental illnesses. As the nation’s first federally funded mental health facility, the concept was groundbreaking. But as history shows us, inclusion does not always mean equality.

Hello, and welcome to “Mental Health Matters,” the National Institute of Mental Health Podcast. I’m Dr. Joshua Gordon, Director of NIMH. And today, we’ll talk with Dr. Martin Summers, author of “Madness in the City of Magnificent Intentions.” We’ll discuss how false ideas of racial differences shaped the care of St. Elizabeths Black patients, and learn how those ideas evolved over time.

I wanted to have this conversation with you about the long and storied past of St. Elizabeths Hospital. It predates the Civil War. In later years, it was run by NIMH and it’s really a fascinating story. Maybe we could start at the beginning and maybe start at the beginning of the story for you. What first got you interested in St. Elizabeths?

Dr. Summers: Well, I actually kind of stumbled into writing a history of St. Elizabeths. I wasn’t trained in the history of medicine when I was in graduate school, I was trained as a cultural historian of the U.S. And I was really interested in gender and sexuality and African-American history.

But growing up in the D.C. area, I was familiar with St. Elizabeths. So that summer of 2001, I was at the National Archives and saw that St. Elizabeths had a record collection. And I just started poking around and I began with the admissions books, which are these just as you can imagine, these massive volumes. And they’re basically ledgers in which the clerks would enter the patients as they were admitted into the hospital. I noticed very early on that there were African-American patients who were being admitted to St. Elizabeths, they were indicated in the admissions book as C for color. Because every patient that was admitted would have some information, some biographical information, where they were born, where they lived, whether or not they were literate, what their religion was, what their occupation was, of course, their gender and their race.

I started looking at existing scholarship on the history of psychiatry and the history of mental illness and realized that there weren’t very many studies out there that use race as a category of historical analysis. So I just decided to abandon the first project and write a history of race and mental illness using St. Elizabeths as a case study.

Dr. Gordon: Martin, that moment where you read that the patient’s mental illness was being blamed on the fact that she had a Black husband. What about that fact triggered a reaction in you?

Dr. Summers: So just seeing those words were incredibly shocking to me. And I think that it was shocking in a way that just say looking at annual reports of the hospital in which they’re talking about this lodge for colored male patients being 15% over capacity. That’s something that I can wrap my mind around because you can kind of see that throughout history, the discriminatory treatment of African-Americans. And that’s something that I encounter on a daily basis in either my reading or my research or my teaching. But to see this term, “the blackness of her husband,” again, not have a framework, a mental framework of thinking, okay, well, why would this have been important? So I think that’s what made it…that’s why it was so shocking.

Dr. Gordon: And having now written the book, done all that research, did you find an answer for why that is important?

Dr. Summers: No, but I speculate. And on the one hand, by the time in the mid-19th century, there was this notion that basically, someone had an underlying morbid condition, right, then there needed to be a precipitating factor that triggered their insanity. And that could be just some shock or something like fright. So sometimes you’ll see in these columns of supposed cause like fright, or obviously more kind of physical being hit on the head or something like that. So, that’s one possible explanation that she was literally shocked into her mania, her husband’s dark complexion. But again, she’s married to him, she herself is Black, so presumably, she would have been used to his color. Again, the fact that this physician or this clerk just framed it as “blackness,” I think also says something about how they were thinking about race as well.

Dr. Gordon: Yeah, absolutely. St. Elizabeths was actually founded in the 1850s, as this country was engaged in a battle over slavery. And I suppose against the wishes of some at the time, it opens in 1855 as the first federally funded mental health facility. Now, tell us about that aspect of it. What prompted the creation of St. Elizabeths?

Dr. Summers: So, St. Elizabeths was founded as part of a larger asylum movement. There were a number of insane asylums that were created in states in the 1840s and 1850s. And one of the pioneers of the asylum movement was Dorothea Dix. And she advocated for the creation of an insane asylum, a federally controlled insane asylum in Washington, D.C. And at the time, there was a great deal of support for that amongst not only the D.C. medical establishment, Congress, because they recognized they needed to have some facility that would house and rehabilitate soldiers and sailors who had become insane. But it was also located in the District of Columbia, which had a fairly large African-American population in the mid-19th century, anywhere between 20% and 25% of the city’s population. The hospital’s founders recognized that they would need to admit African-American patients as well.

Dr. Gordon: I wonder what the process of being admitted to St. Elizabeths looked like at this time.

Dr. Summers: So, in order to be admitted, the individual…typically there needed to be two physicians that testified that an individual was suffering from mental illness. And there had to be two residents of the District of Columbia who could testify to their inability to afford a private treatment. And so, you did have family members who started the process of institutionalization. You also had people who were just picked up on the street by D.C. police officers who would begin that process of admission.

Dr. Gordon: So what was life like for patients at St. Elizabeths at that time? And how did it differ depending upon the race of those patients?

Dr. Summers: In the 19th century, the prevailing therapeutic paradigm and insane asylums was known as moral treatment. And it was the idea that the best way to assist someone to recover their sanity was to just remove them from the environment that had induced their insanity, to begin with, and put them in a tranquil place, make sure that they got lots of rest, a nutritious diet, that they had something to occupy their time.

So when you have Black and White patients in this particular environment, there is a sense that okay, we have this medical professional responsibility to care for all these insane people who are crossing our threshold, but there still is very much a prioritization of White patients. And I think this is just a natural bias that these physicians had at the time.

One of the things that they do is to segregate, right, Black and White patients, but to also basically make an argument that the segregation is necessary therapy for both Black and White patients. Because you don’t want White patients basically interacting with African- American patients, people who they don’t normally interact with outside of the asylum. That somehow, occupying the same space as Black patients might hinder White patients’ recovery. And so you had White patients who typically were housed in the center building, which was made of brick, had fairly spacious wards. Whereas Black men and women patients occupied what were called lodges. And so they were somewhat removed from the center building, they were smaller, they were made of wood, they didn’t have forced air ventilation, they tended to be crowded. As you can imagine, these lodges often became disease environments themselves and ended up actually leading to all kinds of diseases.

If you also think about some of the forms of labor that patients were subjected to, Black patients in particular, being out in the elements, having to dig trenches or build walls or clear forests for farmland, or grading hills, those kinds of things. That that kind of intensive physical activity, while not also not necessarily receiving the same nutritious diet as White patients in the center building also would have had or produced adverse health outcomes for the Black patients. So both racial segregation and for lack of a better term, occupational therapy were considered forms of moral treatment, but they were very different for both Black and White patients.

Dr. Gordon: When you were researching St. Elizabeths, what were some of the worst injustices that you uncovered?

Dr. Summers: So, some of the worst injustices I uncovered go back to really the most fundamental aspect of discriminatory treatment between Black and White patients, and that is really segregation, separating Blacks from White patients. And so, you had I think persistent overcrowding of the wards that Black patients occupied, but it was worse than that in some regards, as well.

So, in 1887, the hospital builds a building specifically to house insane convicts and people who are diagnosed as criminally insane. And most of these insane convicts were federal convicts who had become mentally ill during their time in prison and they are relocated to St. Elizabeths. And those people are considered to be particularly dangerous like homicidal. Because the hospital staff doesn’t have enough space for Black patients, they made a decision to house African-American men regardless of their diagnosis or their legal status. So you had Black men who would not have been considered criminally insane, not been diagnosed as being criminally insane. And Black men who had never been convicted of any crime, being housed in the same facility with the criminally insane and with insane convicts. And while this was a decision that was made because there was not enough space to house African-Americans at the time, it also still revealed certain thinking about Black men, in particular, Black men as being natural criminals. So that was really one of the worst injustices that I saw during my research.

Dr. Gordon: It was clear that views on race influenced medical care long after emancipation. What were the core beliefs that led to even the medical establishment treating Black patients differently?

Dr. Summers: So at least up through the mid-20th century, there was just this fundamental belief that the Black and White psyches were fundamentally different. And actually, you see this in a number of ways. Prior to emancipation, there was a medical consensus that it was rare for African-Americans to become insane. The mentally ill African-American was a rarity because they were, “primitive peoples” and so they did not have brains that were sufficiently developed to deteriorate in the first place.

Also, in the mid-19th century, there’s this belief that insanity is primarily a disease of civilization. And so, it’s people who are capable of dealing with the stresses and strains of living in increasingly modernized society, taking care of themselves. Or perhaps someone might study too much, so over-study was thought to be a cause of mental illness. And in addition to Black people supposedly being more primitive and having a built-in biological immunity to insanity, there was also this idea that because the overwhelming majority of African-Americans in the early to mid-19th century were enslaved, that they did not have the kinds of worries or preoccupations that might actually drive someone who was not enslaved insane. And so in a sense, slavery protected them from becoming enslaved. The benevolent masters took care of all their needs and Black people were not exposed to the kind of environmental stressors that might lead them to becoming insane.

And after the Civil War, this kind of changes significantly. By the ’80s and the 1890s the generation after slavery or generation after emancipation, more and more African-Americans who during slavery, if they had exhibited evidence of being mentally ill, would have just been dealt with by their master, right? Maybe locked in an attic or taken care of by their family members in the slave cabins. But now after emancipation, these mentally ill African-Americans are becoming kind of legible to the medical establishment as well as the state. And so, you have more and more African-Americans being admitted into insane asylums, so much so that Southern states are beginning to build insane asylums, specifically for color population.

And so that leads to this narrative within the medical establishment that in fact, it’s freedom that contributes to this epidemic of insanity among African-Americans in the late 19th century. That African-Americans during slavery, they didn’t have to worry about putting food on their table, they didn’t have to worry about voting. They didn’t have to worry about all of these things that… They certainly didn’t study too much because it was illegal to teach enslaved people to read and write. But now, all of that is gone and African-Americans are expected to make a way for themselves and thrive economically, and participate in the political system, and essentially have to compete with Whites now. And they’re not capable of doing that and that is, in fact, driving them insane. And so, that’s how physicians explain these reported rises of insanity among African-Americans in the late 19th century.

Dr. Gordon: So, Martin, I can only imagine you, as a researcher, in this day and age reading and learning about the way Black patients were treated in the 19th century, and even into the 20th century at St. Elizabeths. What did that feel like for you?

Dr. Summers: So in some ways, it wasn’t surprising at all. In other ways, it was surprising, but from an interesting perspective the ways that many Black Washingtonians thought of St. Elizabeths, not necessarily as this racist institution, but rather as an asset that might help them deal with a problem that was internal to their family or their community.

One individual who worked at the Treasury Department, a Black man who worked at the Treasury Department, he was a widower, and he had about four or five children. One of whom was epileptic and who was institutionalized at St. Elizabeths. And he did actually bring his son home. And he writes back and forth with the superintendent updating the superintendent on condition of his son. At one point, he actually was to return him. He basically says, “I don’t wanna return him. I want him to stay amongst people who love him, but I work and I can’t be there to constantly monitor him. And he occasionally goes out into the street and the children wanna make fun of him.” So here’s the case of this again, African-American, a federal employee who probably is already inclined to think about the government in very favorable way, turning to this government institution and saying, “I need help, will you please take my son back?” But it had to have been a really heart-rending decision to institutionalize his son again.

Dr. Gordon: It always is. I’ve had that conversation with families too many times, it’s always heartbreaking. Thinking about St. Elizabeths again, let’s fast forward to the 1940s. At that point, I understand the hospital was still segregated. There were no Black doctors until the 1950s for example. For some of our listeners, that’s within their lifetime. When did the situation start to change, and how did those changes influence care?

Dr. Summers: The problems that existed in St. Elizabeths certainly persist into the mid-20th century. So you still have obviously, segregation and that segregation produces overcrowded African-American wards and underutilized White wards for instance. You also have different types of therapy that are being used against Black and White patients in different ways. And this is a case of Black patients at St. Elizabeths not having the same kind of access to resources that White patients did. You also still had disproportionate “employment” of Black patients in the laundry and in the kitchens. So there’s very much a racial differential that persists in terms of treatment of Black and White patients. The use of psychotherapy, for instance.

Now, St. Elizabeths is a massive hospital. By the mid-20th century, there’s something like 6,000, 7000 patients. And the overwhelming majority of patients at St. Elizabeths were not given psychotherapy. But even those who were, particularly Black patients who were given psychotherapy, it was always kind of non-intensive psychotherapy, really just attempting to address the surface symptoms and not really trying to go and discover these deeper complexes. What I argue in the book, it seems like psychotherapy was employed with Black patients just to get them to the point where they could actually engage in labor, particularly labor in the hospital’s laundry or the hospital’s kitchen.

Dr. Gordon: When did the situation change at St. Elizabeths? What drove integration and how did that influence care?

Dr. Summers: Well, there are a couple of things that led to integration. I would say one of those developments was internal to the psychiatric profession itself, and one of those independent of the psychiatric profession. This idea that the Black and White psyche were fundamentally different had really shaped psychiatric thought over the 19th century and well into the 20th century.

But by the 1940s, you have the emergence of what we might refer to as psychiatric universalism, race is increasingly being questioned by scientists, both by natural scientists as well as social scientists. And increasingly within the psychiatric profession, there’s this belief that Blacks and Whites respond in similar ways to cyclical stress. Essentially, the Black psyche and White psyche fundamentally are the same. And so, this is actually beginning to shape thinking within the psychiatric profession about how do you treat Black and White patients. In fact, you increasingly treat them the same way. And so that’s one important development.

The other important development here is that there’s just a lot of outside pressure both from the federal government, as well as civil rights activists in the 1940s and 1950s that also contributes to integration of the hospital. Integration begins in the staff, right, in the nursing and attendant staffs. And this is largely a result again, of progressive leadership in the Department of Interior, which was the parent agency of St. Elizabeths until World War II, and then is transferred over to the Federal Security Administration.

But in 1941, Franklin Delano Roosevelt issued Executive Order 8802, which prohibits racial discrimination in hiring and federal agencies. So that’s really when you begin to see St. Elizabeths hiring Black attendants and Black nurses. Although they don’t have a Black psychiatrist on staff until 1955. And they began integrating the wards in the early 1950s. And part of that again, is a result of psychiatric universalism. But also part of it is an increasing pressure by civil rights activists who are making an argument that we cannot have a government institution in Washington D.C. that is practicing racial segregation as the United States is trying to position itself vis-a-vis the Soviet Union as the beacon of democracy.

Dr. Gordon: Moving forward to the 1960s, now we have the Community Mental Health Act to push to deinstitutionalize patients. In 1967, the hospital was transferred to the National Institute of Mental Health where it would remain for about 20 years before going back to the District of Columbia. And St. Elizabeths starts moving towards…like many mental health facilities in the country, moving towards more outpatient and community-based work. What propelled that movement? How did it change the landscape? And what work were the providers doing?

Dr. Summers: Well, one of the things that contributed to the decentralization of mental health care delivery was the patients’ rights movement in the 1960s. Beginning with the challenges to hospitals for the right to treatment, right, so that you just couldn’t warehouse an individual without having some kind of treatment plan. And then later in the 1960s, the challenging or the right to be treated in the least restrictive setting.

In the 1960s, what facilitates this out into the community is the psychopharmacological revolution and introduction of Thorazine and other psychotropic drugs, which allows hospitals to begin releasing larger numbers of patients back into the communities and providing aftercare as well as outpatient services. And then along with that, the challenge to hospitals amongst patients to be treated in the least restrictive settings ends up leading to deinstitutionalization by the early 1970s. So, they’re obviously providing outpatient mental health services. They’re also providing job skills training for patients who have been released. It’s very interesting because they’re not just providing outpatient mental health services, but they’re also functioning as community centers in some ways. They’re hosting conferences and speakers on subjects that range from education to the Black family, to teenage pregnancies. These community mental health centers were also just thought of as ministerial resources for these communities that extended beyond just providing mental health care.

Dr. Gordon: Bringing us to the present, Martin, what can you tell us about the hospital’s recent developments, what role it plays in mental health for the citizens of the District of Columbia today?

Dr. Summers: What’s very interesting is that the original campus had been closed for several decades and it was just reopened. So all of these classic red-brick, Gothic-architectural-style buildings that made up St. Elizabeths in the late 19th century are now occupied by the Homeland Security Department. There has been a new state-of-the-art hospital that was built, which is very nice. But my sense is that the majority of patients at St. Elizabeths now are really forensic patients. They do provide outpatient services, but those patients who are institutionalized there are mostly forensic patients. So those individuals who have been found not guilty of a crime by reason of insanity, or that are undergoing psychiatric evaluation before they go on trial.

Dr. Gordon: Despite progress in many areas, disparities in mental health care still exist for Black Americans today. Right now as we’re talking there are people who still can’t get the help they need. We know that discrimination plays a factor, access plays a factor, economics play a factor. Are there any lessons that we can learn from the history of St. Elizabeths that we can use to try to figure out how to address mental health disparities in this country?

Dr. Summers: I think the question of access is a really important one. Because when I started this project, I was under the impression that African-Americans have always had a kinda antagonistic relationship to psychiatry. And that they tend to turn to say the church to deal with emotional or mental distress. And they harbor this idea that psychiatry is a very biased field. And there’s some truth to that, obviously.

But one of the things that became clear to me doing this research is that African-Americans have always had a healthy skepticism of psychiatry, but at the same time, have engaged it when they needed to. I think that it’s important to really understand that if we provide access to African-Americans, that African-Americans will take advantage of mental health care services.

Dr. Gordon: That’s a hopeful thought for our current situation. I’m wondering if you could mention what are you most optimistic about for the future of mental health care given your understanding of its history and particularly for Black Americans.

Dr. Summers: So, the decline of stigma I think. I really think that is significant. And I’ve seen it in my lifetime. When I started this project, one of the claims is that African-Americans as well as other people of color underutilize outpatient services, which contributes to their overutilization of inpatient services or institutionalization. And the arguments that are made for that as I’ve talked about before that African-Americans tend to process or cope with mental stress or emotional distress within a religious framework. And they tend to turn to the church or their pastors. And that there’s just very little willingness to discuss mental illness or frame emotional stress as mental illness. And I think that increasingly, there’s an openness to talking about it from celebrities to just college students. And I think that’s a significant development and this is something that I’m optimistic about.

Dr. Gordon: Dr. Summers, thank you for joining us today.

Dr. Summers: Thank you. It was wonderful talking with you.

Dr. Gordon: This concludes this episode of “Mental Health Matters.” I’d like to thank our guest, Dr. Martin Summers for joining us today. And I’d like to thank you for listening. If you enjoyed this podcast, please subscribe and tell a friend to tune in. We hope you’ll join us for the next podcast.

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