M. Summers/Chapter Six/p. 1

Dear Social Science Research Participants,

Thank you for inviting me to participate in your works-in-progress series. I am looking forward to meeting you all and discussing this chapter draft in a few weeks. I would like to briefly place this chapter in the context of the larger book project.

This is a history of the African American community’s relationship to Saint Elizabeths Hospital, a federal mental institution in Washington, D.C. The study covers the entire history of the hospital as a federal facility, from its founding in 1855 to 1987, when the federal government transferred control to the District’s Department of Mental Health. Chapters five, six, and seven examine various dimensions of the superintendency of William Alanson White, who headed the hospital from 1903 to 1937. Initially, I had planned on presenting a draft of chapter five, which explores the emergence of dynamic psychiatry (Adolf Meyer’s psychobiology and Freudian psychoanalysis) and its impact on the treatment of African American patients. I thought that there would be section in that chapter on psychotherapy. The deeper I got into that chapter, the more it became about dynamic psychiatry and Saint Elizabeths’ staff’s production of knowledge about the “black psyche.” I realized that a section on psychotherapy would make the chapter too long,so I decided to fold psychotherapy into a chapter that I had originally thought would only be about somatic therapies. As such, the chapter feels a little disjointed to me but I’m not sure if it will read that way to others. I’d be particularly interested in your thoughts on that (and if I need to develop a stronger analytical thread to tie the two sections together). Of course, I would love to hear any other thoughts that you may have about how to make the chapter stronger.

I should also say that it is a bit longer than I had hoped, so any suggestions on where I can cut and still maintain the integrity of the argument will be most appreciated. If you’d only like to focus on the section on psychotherapy and let me know how to strengthen it, that would be okay with me as well.

Thanks,

Martin Summers

Chapter 6

Psychotherapy, Somatic Therapies, and African American Patients at Saint Elizabeths, 1903–1907

DRAFT COPY: PLEASE DO NOT COPY, CITE, OR CIRCULATE WITHOUT PERMISSION OF THE AUTHOR

With its emphasis on the individualization of mental disease, dynamic psychiatry held out the promise of more efficacious treatment modalities. If psychiatrists could get beneath the surface of patients’ symptoms and understand their“meanings and values,” then they had a better chance of facilitating mentally ill individuals’ readjustment to their social environments.[1]The therapeutic procedures associated with dynamic psychiatry rendered the primary therapeutic model of the nineteenth-century asylum, moral treatment, obsolete. William Alanson White trumpeted the advances of the new psychotherapy of the “modern hospital” over the “old asylum’s” moral treatment regimen—which he identified as occupational or industrial therapy—in a 1921 article on dementia praecox. “[M]any have come to believe, and this applies to the laity solely,” he argued, “that the be all and end all of therapeutics for the mentally ill is kindness, sympathy, and work, the work taking very largely the form so familiar to you in the recent development of occupational therapy: basket-making, bead stringing, leather tooling, modeling, needle work, toy-making, etc.”Although he acknowledged that the remnants of moral treatment still had some practical value in “socializing” the mentally ill into “useful occupations,” White considered the older therapeutic model a subsidiary to the intensive psychological work that psychiatrists needed to do with their patients.[2]

Skepticism toward moral treatment—and the principle of inmate labor that underpinned it—had been in the atmosphere surrounding Saint Elizabeths for some time. While White’s skepticism was influenced by his commitment to dynamic psychiatry, others doubted the therapeutic value of labor because of the difficulty in getting patients to work. This became a particular issue in the 1906 congressional investigation, when members of the committee criticized the work regime of the hospital. Their complaints were not framed as charges against the administration as much as they were expressions of disappointment at both military and civilian patients’refusal to perform labor for the hospital. Soldiers’ and sailors’ refusal, the committee stated in the report’s summary, was motivated by their belief “that they are entitled to a life of entire ease and freedom from work, as they would be were they in entire possession of their mental faculties and inmates of a Soldiers’ Home.” While the committee attributed military patients’ idleness to their sense of government entitlement, they suggested that civilian patients’ reluctance to work was animated by an entitlement of a different sort. Both black and white patients avoided “voluntary labor” because of its particular racial valence. “[T]he white people who go to the institution from the District of Columbia are averse to performing anything in the nature of manual labor, as they are inclined to think that such labor should be performed by the colored inhabitants to the institution,” the committee reported. “On the other hand, the colored inhabitants of the institution are averse to performing labor because they feel that all labor is entitled to pay.”[3]Staff members at Saint Elizabeths were not the only ones who filtered their expectations about moral treatment through a racial screen—employing black female patients almost exclusively in the kitchens and laundry, for example; the patients themselves interpreted the staff’s directives to labor through their own ideas about what constituted appropriate management of their bodies.

To be sure, elements of moral treatment persisted at Saint Elizabeths. In addition to occupational or industrial therapy, the staff continued to subscribe to the therapeutic possibilities of recreation and leisure. The hospital library was well-stocked, containing not only books, but approximately 150 U.S. and Canadian newspapers, including the African-American-owned Colored American and Richmond Planet. The hospital started an in-house newsletter, The Sun Dial, in 1917and encouraged patients to make literary and editorial contributions to it.[4] Music and theater remained part of the therapeutic repertoire of the hospital as well. In 1907, Congress appropriated $75,000 for the construction of a large auditorium, which White proudly pledged to make “a modern theater in every sense, seating approximately 1000 people [and] provided with . . . modern stage equipment.” The staff put on weekly dances for the patients in Hitchcock Hall and, by 1911, the auditorium was equipped with a “moving picture apparatus.” Patients also staged their own productions and, by the late 1920s, they were performing them not only in Hitchcock Hall, but on Washington’s radio stations as well.[5]The administration continued to provide for the spiritual needs of the patients, employing chaplains from five different Protestant denominations who each spent two months of the year conducting service in the hospital’s chapel. Catholic patients were also able to regularly attend masses on the hospital grounds.[6]The core principle of moral management—that is, the importance of creating as normal a social environment for the mentally illas possible—permeated everyday life at Saint Elizabeths even if the staff no longer explicitly referenced it as a treatment modality.

By the 1910s, however, Saint Elizabeths’ psychiatrists were able to select from a broader array of therapies. As increasing numbers of members of the clinical staff were trained in dynamic psychiatry, psychotherapy was employed with greater regularity on the wards. Not all patients were considered appropriate subjects for psychotherapeutic intervention, however. In general, psychiatrists believed that once a psychosis had progressed to the point that an individual needed to be institutionalized, it was less amenable to clinical approaches such as talk therapy. Even though White rejected the “pessimism, voiced for example by Freud, as to the impossibility of improving the Praecox by treatment,” he was hardly optimistic that psychoanalysis could be an effective form of mass treatment, especially given the high patient-to-staff ratio at the hospital. Indeed, at various points he suggested that the categories of patients for whom psychoanalysis was the most efficacious form of treatment were those suffering from psychotic disorders such as paranoia and psychoneuroses such as neurasthenia, hysteria, psychasthenia and their allied disorders.[7]

White and others did not explicitly use race as a criterion in defining the ideal target for psychotherapy; nor did they provide racial breakdowns of the overall statistics of psychotherapeutic treatment in the hospital’s annual reports. Nonetheless, an examination of the case files of black patients between roughly 1905 and 1935 does reveal that Saint Elizabeths’ psychiatrists psychotherapeutically-engaged African Americans, and in ways that both revealed a concern for their mental well-being and a deep sense of racial antipathy. To be sure, they rarely did the kind of intensive psychoanalytic work that was central to dynamic psychiatry’s treatment model. But they did do a kind of non-intensive psychotherapy that was aimed at assessing their patients’ present state of mind and evaluating their progress. In other words, staff psychiatrists were generally more concerned with the surface manifestations of blacks’ psychoses than they were at getting at the roots of the complexes that caused their psychoses. This may have been a product of the overdiagnosis of dementia praecox among African American patients, a psychosis that was generally still considered to be intractable from a psychoanalytic perspective, White’s quibble with Freud notwithstanding. Likewise, as we saw in the previous chapter, to the extent that dementia praecox was seen as a reversion to the primitive stage of the race’s development, some psychiatrists believed that it was easier for African Americans to recover given that they were not as evolutionarily advanced to begin with, making intensive therapy unnecessary.But regardless of the type of psychotherapy employed among African American patients, the tension between a desire to see racial difference and an impulse to heal led to a great deal of clinical ambiguity and ambivalence on the wards.

African American patients were not merely objects of medical scrutiny and targets of institutional management however. They interacted with the staff in ways that challenged their authority to not only determine the clinical encounter, but to establish particular truth claims about black insanity as well. Yet they also interacted with the staff in ways that reaffirmed their identities as sufferers of mental illness. In other words, everyday life for African American patients in Saint Elizabeths consisted of negotiating the multiple dimensions of power—the medical power to define illness and health, the social power to define race, and the immanent power to define one’s own identity—that suffused the institution.[8]

Psychotherapy was not the only treatment modality that Saint Elizabeths’ staff used with increasing frequency during White’s administration. Despite the ascendancy of dynamic psychiatry and its emphasis on the psychogenic dimension of mental illness, psychiatrists continued to employ somatic therapies that were aimed at both alleviating acute symptoms as well as curing specific mental diseases. These included hydrotherapy, malarial fever inoculation therapy, insulin/metrazol shock therapy, and psychosurgery.[9] These somatic therapies received varied levels of support from the hospital’s administration and they had different shelf lives. Moreover, as we will see, race became an important variable in the staff’s employment of particular therapies.

Psychotherapy and the African American Subject

Psychotherapy was a broad category of treatment that encompassed many different strategies. It included talk therapy based on psychoanalytic theory, to be sure, but went beyond this. Indeed, White separated discussions of psychotherapy and psychoanalysis in his textbook Outlines of Psychiatry. Moreover, he pointed to the psychotherapeutic benefits of a particular form of hydrotherapy which was generally considered to be a somatic-based treatment modality. “The continuous bath, in spite of all that has been written about its physiology,” he asserted, “to my mind accomplishes its results psychotherapeutically, it is a concession to the regressive tendency minus the harmful effects of narcotic and sedative drugs.”[10]White also expected the publication of The Sun Dial to have psychotherapeutic benefits. More than a mere “news organ,” it would be a vehicle for “a new literature addressed to the mentally ill by the physicians, which will be of direct assistance to the patient in enabling him to understand the sort of thing that has gone wrong with him.” The translation of specialized psychiatric knowledge into usable information for patients was only part of the psychotherapeutic process however. White hoped that these articles would be the catalyst for some patients to initiate a relationship with the clinical psychiatrists. “[T]o that end,” he informed the Board of Visitors, “I expect to ask the psychotherapists (there are now two of them on the staff of the hospital) to take a dispensary room at a certain hour on dispensary day, and receive patients from all parts of the hospital who wish to talk over their problems, size up the situation, and if apparently it is one that looks favorable make arrangements for regularly meeting the patient and trying to help him.”[11]

For White, the potentially most efficacious form of psychotherapy was psychoanalysis. It was superior to the most commonly used form of early psychotherapy, suggestion, White argued, because the latter only addressed the superficial manifestations of mental illness. Like many of his colleagues, his embrace of the more scientifically-grounded psychoanalytic methods over suggestion was also an attempt to distance himself from the forms of psychotherapy associated with the Christian Science, New Thought, and mind cure movements of the late nineteenth century.[12] Psychoanalysis was more rigorous, White believed, and required greater commitment from both the physician and the patient. The relationship between the two began with an “initial talk” in order to “orient [the psychiatrist] with regard to the general make-up of the personality” of the patient. Once it was determined that the individual was a good candidate for psychoanalysis, the psychiatrist needed to schedule regular sessions (what White called séances) in order to probe his or her unconscious. This was done through a number of procedures, including free association, word association, and investigation into the patient’s “dream life.” The environment in which the psychoanalytic encounter occurred was extremely important. The patient needed to be protected from external distractions, making it easier for any internal complexes to be detected as the patient spontaneously responded to the psychiatrists’ queries and cues. In order for free association to be effective, for instance, White suggested that the patient be in a semi-hypnotic state, fixated on some “monotonous sensory stimulus that dominates the sensorium and shuts out less insistent and inconsiderable sensations, such as the buzzing of a faradic coil.” But what was, perhaps, most important was that these sessions take place over the course of months. The intense plumbing of the psychic depths required that a strong rapport exist between the psychiatrist and the patient. The development of this rapport was dependent on the psychiatrist approaching the patient from a nonjudgmental and empathic position. This rapport-building, or transfer, took a considerable amount of time, but once effected, made “for a more wholesome, a more robust philosophy of life, and finally when all the submerged complexes and mechanisms of the symptoms have been uncovered our patient emerges literally born again.”[13]

By the World War I period, psychotherapy was a sufficiently regularized treatment modality at Saint Elizabeths to warrant a mention in the institution’s annual report. Between July 1918 and July 1919, there were 111 patients who were given “special psychotherapeutic attention”; interestingly, a majority of them were identified as dementia praecox types. To be sure, this was a paltry number compared to the 2,100 patients given hydrotherapy treatments and the approximately 3,500 patients who resided in the institution during the same time span.[14]The fact that such a small percentage of overall treatments ended up being reported to the institution’s oversight department reflects the extent to which White considered psychotherapy to be central to Saint Elizabeths’ identity as a modern psychiatric hospital. In addition to the individualized sessions that White described in his textbook or that he envisioned taking place on dispensary day, an early form of group therapy emerged in the postwar period. The superintendent reported to the Board of Visitors in 1919 that one of his staff members had begun “a new experiment along these lines by grouping patients who have the same type of mental difficulties and giving them psychotherapeutic talks in classes of a dozen or twenty as a preliminary if necessary for more individual work.”[15] It is unclear if the clinical psychiatrist used these gatherings to prompt patients to engage in a kind of confessional therapy or if he merely used them as a way of recruiting patients into one-on-one sessions. What is clear is that by the end of the war, more and more patients were being drawn into a new psychotherapeutic regime.