“An Example for the Rest of the Nation”

This chapter covers the various challenges to Saint Elizabeths’ segregationist culture made by both black Washingtonians and the federal government over the first half of the twentieth century. It begins by exploring the staff’s inability to effect an absolute racial segregation in the wards, which was the result of the hospital’s constantly being in a state of overcapacity. The chapter also looks at the changing demographics of the patient population following World War II, when the army and navy stopped sending its mentally ill service members to Saint Elizabeths. It then turns to an examination of local community members’ and the federal government’s challenges to discrimination against black medical students, mistreatment of African American patients in the 1920s and 1930s, and exclusionary and segregationist employment policies. This chapter covers the desegregation of the hospital staff, from attendants and nurses in the 1930s and 1940s to physicians in the 1950s.

“He Is Psychotic and Always Will Be”

This chapter continues an examination of the superintendency of William Alanson White but offers a more granular discussion of how ideas about racial difference shaped the clinical encounter in the era of dynamic psychiatry. Specifically, it looks at how Saint Elizabeths’ staff applied particular somatic “therapies”—including seclusion, restraint, and hydrotherapy—to black female, white female, black male, and white male patients. It also argues that the clinical staff’s limited psychotherapeutic engagement with African American patients was further undermined by two things. One was the psychiatrists’ assumptions about the inaccessibility of the black psyche—either because of the absolute cultural foreignness or natural duplicity of African Americans. The other was their tendency to prioritize black patients’ rehabilitation as laborers. Finally, the chapter looks at the quotidian ways that patients exerted their agency in the clinical encounter by resisting medical surveillance and institutional management.

Conclusion

The conclusion provides a summation of the book’s main arguments and offers suggestions for further research in the history of African American mental health. It reasserts the two central theses. First, Saint Elizabeths’ psychiatrists’ construction and reaffirmation of the white psyche as the norm produced a great deal of ambiguity regarding the nature of black insanity. This contributed to the prioritizing of the white sufferer of mental illness and the marginalization of mentally ill blacks. Second, African American patients and their communities exercised agency in their interactions with Saint Elizabeths, both to shape the therapeutic experience and to assert their status as citizens. This latter argument suggests that the orthodox view that African Americans have generally had an indifferent or antagonistic relationship to psychiatry needs to be rethought, which will require further historical scholarship, particularly with respect to African American activism within the realm of mental health care.

“Mechanisms of the Negro Mind”

This chapter is the first of three that covers Saint Elizabeths during the tenure of one of its most famous superintendents, William Alanson White, who led the hospital from 1903 to 1937. White represented a new approach to mental illness. Dynamic psychiatry moved beyond contemplating mental disorders based on static descriptions of symptoms and, instead, stressed the importance of assessing individuals—including constitution, life experiences, conscious and unconscious memories—and their interactions with their social environments. This chapter provides a bird’s-eye view of how this individualization of mental disease both meshed and was in tension with the race-based comparative psychology research that White encouraged at Saint Elizabeths. Despite their engagement in research that presupposed the existence of distinct black and white psyches, members of the hospital’s clinical staff were ultimately unable to reify race as a scientific category of human difference.

Care and the Color Line

This chapter examines how the medical consensus about black mental illness in the post-Reconstruction era contributed to the unequal treatment of African American patients at Saint Elizabeths and, in turn, how black patients and their communities sought to manage their therapeutic experience. The tendency to construct black madness as particularly violent and depraved—evident in the profession’s conflation of African American insanity with mania—led to Saint Elizabeths housing black male patients, regardless of their diagnosis and civil status, with insane convicts and the criminally insane. Both African American male and female patients were sequestered in overcrowded, substandard wards. They were also subjected to menial forms of labor, especially laundering and cooking, that masqueraded as therapy. Yet patients and their families made their own interventions in the clinical relationship and attempted to shape the treatment that they and their loved ones received.

“From Slave to Citizen”

This chapter covers Saint Elizabeths during the post-Reconstruction era and examines the medical professions’ changing ideas about black mental illness and black Washingtonians’ interactions with the hospital in a new era of limited citizenship. A postemancipation discourse emerged among physicians in the 1880s and 1890s that fundamentally differed from the antebellum medical consensus that insanity was rare among black people. Instead physicians began to attribute a perceived increase of black insanity to freedom itself. What the psychiatric profession—which now included individuals trained in neurology—could not agree upon was whether blacks’ new susceptibility to madness was a result of their cultural or biological underdevelopment. Despite this new consensus that associated black mental illness with freedom, this chapter argues that the increased admissions of African Americans to Saint Elizabeths in the 1890s was more the result of black families assertively using the federal institution as an important resource.

“Humanity Requires All the Relief Which Can Be Afforded”

This chapter covers the prehistory of Saint Elizabeths, including efforts to manage the insane in the District of Columbia in the first half of the nineteenth century and the establishment of the hospital in 1855. It examines how local officials, the federal government, and District residents addressed the problem of mental illness through public policy and private care. The chapter also reveals the role that ideas of racial difference played in decisions about where to locate Saint Elizabeths’ and its original design. Maintaining strict separation of the races became a central objective of the hospital’s first superintendent, Charles H. Nichols, as he laid out the hospital. This objective was in keeping with the moral treatment model of nineteenth-century asylum psychiatry.

From Model to Emblem

This chapter examines the comprehensive community mental health care movement, deinstitutionalization in the 1970s, and the transfer of control of Saint Elizabeths from the federal government to the District in the 1980s. It focuses on the Area D Community Mental Health Center, which was located at Saint Elizabeths and served mainly low-income black neighborhoods in Southeast and Southwest Washington, DC. It looks at how efforts to provide mental health care and other services to so-called ghetto residents were undercut by disinvestment in urban areas. Dwindling resources and services, combined with deinstitutionalization, contributed to a growing epidemic of homelessness in the nation’s capital. But the community mental health care movement and the ultimate transfer of the hospital to the District reveal the ways that black Washingtonians invested their relationship to Saint Elizabeths with their claims to being equal citizens of the District and of the nation.

Whither the Negro Psyche

This chapter covers the desegregation of the hospital’s wards in the 1950s. It begins by examining the emergence of a universalist turn within psychiatry that rejected earlier assumptions about the existence of racially distinct psyches. By the 1940s and 1950s psychiatrists began to think about mental illness among African Americans on a par with mental illness among whites. This was reinforced by advances in psychopharmacology and the development of social psychiatry, the latter of which took seriously the role of racism in producing mental illness. This universalist turn was more responsible than grassroots activism or government directives for the racial integration of Saint Elizabeths’ wards, although the latter did play a role. Despite the ascendancy of a nonracialist conception of the psyche in the postwar period, however, racism and racial ambivalence continued to play a part in defining the experience of African American patients.

Mental Hygiene and the Limits of Reform

This chapter examines key innovations that began to project Saint Elizabeths’ psychiatric authority into the community—specifically, the outpatient clinic, psychiatric social work, and child guidance centers. Broadly defined as mental hygiene, these efforts were aimed at reducing the number of institutionalized patients and providing them follow-up care. They were also aimed at preserving the mental health of individuals and consequently preventing their institutionalization in the first place. The chapter is in part concerned with how black patients and their family members shaped the outpatient experience. It also addresses the role of Washington’s segregationist culture and politics in limiting these larger mental hygiene reforms among the District’s African American community.