Background to this project, with a note on positionality
I often start my introductions with a disclaimer: I work in a School of Nursing, but I am not a nurse. In fact, I am an historian. I am also not American, I’m Australian. And I am white. So how did I come to be working on a project about the history of psychiatric racism in the American South?
My PhD (completed in Australia) was about the way that psychiatric discourses in late 19th century Sydney created the idea of the juvenile delinquent. As I pursued my academic career, I realized that nurses had had a part to play in that history. I came to work closely with nurses by accident—as I finished my PhD I worked as a research assistant for the Dean of the School of Nursing, and he recognized the importance of history for nurse education. My research expanded to include the role of nurses in psychiatric history, with a particular focus on the work of American nurses. The result of that work is a book published by Rutgers University Press called “Talking Therapy: Knowledge and Power in American Psychiatric Nursing”.
In 2015, I left Australia to start a new job at Emory University in Atlanta, Georgia. As I finished my work on nurses, I realized that no one had really thought about their role in the South. Most of the histories of both psychiatry and nursing focus on Northern hospitals or problems, maybe out of an assumption that things in the South were just terrible, or so backward as to be not worth talking about. But my research suggested the story was a little more complicated than that. As Darlene Clark Hine, Vanessa Northington Gamble, John Dittmer and many others have written, African Americans were active in the creation of their own health care systems. Southern Black nurses went North to school, finishing Masters and PhD degrees, sometimes returning to the South with their knowledge and determination to end inequality. Northern white nurses usually resisted Black women in the profession, but some of them came South to help build new programs and sometimes, to fight segregation. The same is true of psychiatrists. The idea that segregation was a Southern problem, that the South was ‘exceptional’ or backward, is not borne out by this evidence of extensive networks and the transmission of both people and ideas.
Yet inequalities do exist, and they are often worse in the South. Alabama, Mississippi and Georgia are currently ranked 46th, 48th and 50th respectively by Mental Health America in terms of access to care. Largely, these disparities are a result of history. As I gathered material about the history of psychiatric nurses in the South, I began to understand how segregation was both maintained and then challenged by the people who lived and worked in large state hospitals, which were often the only facility available for people with mental illness. But they weren’t just places of treatment. The state hospital systems across the southeast were often repositories for a host of other social problems: poverty, aging, alcoholism, family disputes, neglect of children, dumping of the disabled. When I first moved to Atlanta and talked to people about my interest in the history of mental health, someone said, “Oh, here in the South we put our crazy on the porch and give it a cocktail.” Actually, the South used to put its crazy (and its queer, disabled, feisty or just plain different) into an institution, usually called something like Central State Hospital, and left them there to die. In 1960, Central State Hospital in Milledgeville, Georgia housed more than 12,000 people.
Much has been made of the closing down of these hospitals, the movement called “deinstitutionalization” or “Community Mental Health”. As I thought about trying to unpack the causes of current disparities, I saw clearly that the 1960s had been pivotal for the future of mental health. Three major sets of legislation: the Community Mental Health Centers Construction Act of 1963, the Civil Rights Act of 1964, and the passing of Medicare and Medicaid in 1965 all created a perfect storm for the reconfiguration of mental health systems. And ideas about race were central. Not only did segregation exist in the formal structures of the US health system, including psychiatric hospitals, it influenced the way that health professionals thought about the nature of the human psyche itself. Old ideas that had been used to justify and reinforce slavery continued to permeate medical and psychiatric discourses, promulgating the belief that African Americans were more childlike, more aggressive, less likely to experience depression, less amendable to certain types of treatment. In his book from 2010, Protest Psychosis: How Schizophrenia Became a Black Disease, Jonathan Metzl demonstrated the very deliberate process by which American psychiatry continued to reinforce ideas of psychiatric difference which has had disastrous consequences not just for African Americans with mental illness, but for the way that Black people are conceived and represented. Psychiatric hospitals were an integral part of this process.
The rest of this project will try to unpack this complicated history piece by piece, starting with the impact of the Civil Rights Act on the state mental health systems in Georgia, Alabama and Mississippi. Exploring the ways that each of these states responded to the mandate to provide racially integrated services reveals much about the existing practices and underlying attitudes about Black mental health. Alabama and Mississippi resisted desegregation while Georgia did not, and those patterns have had long lasting consequences. But the Civil Rights Act of 1964 did not solve the issue, nor did it eradicate racism. By tracking subsequent legislation and class actions, this project will analyze the way that activists, lawyers, and patients continued to fight for their rights at the intersection of psychiatry, disability, and the law.
A NOTE ON POSTIONALITY
Since I’ve moved to Atlanta, I’ve had a number of people (usually white women) ask me why I care about social justice issues so much. I am never sure how to answer. What I think they are asking me is if there is something in my personal history that compels me to care about poverty or abuse or neglect or racism. Then I am confused, because does that mean you can only care about those things if you’ve experienced them? This project is not about me. It’s about how disparities are created, it’s about how racism and violence are central to the construction of American society – to most societies that have been created off the back of colonization and capitalism. I cared about that when I was in Australia, and I care about it now that I am in Atlanta.
At the same time, I am very much aware of my positioning as a white woman from a private, privileged university that doesn’t necessarily have a spotless record when it comes to matters of Civil Rights. Ultimately, it’s because of that position that I am compelled to undertake this project. As a person, I am interested in ideas about mental health, what it is, how it’s defined, what constitutes treatment, who has access to it. As a historian, I see how these things have been created over time, and how some groups of people continue to be treated worse than others. Plenty of people have written histories of psychiatry that center the white experience from both a patient and a provider perspective. Why retell a story that’s already been told? Too often, it is assumed that psychiatry was the purview of white people, as an intellectual exercise and as a health service, and that assumption continues today to the detriment of thousands.
What gives me the authority to tell this story? Nothing in particular. In some ways, I didn’t even seek it out. It became obvious to me that there was a gap in the history, and when I started asking questions people started talking. I am an outsider in so many ways, an academic, white, not American. I have a lot to learn. There is a lot I still don’t know. I try to be humble and open, to act as a conduit for what emerges, to try and tell stories of survival as much as oppression, to pay attention to the nuances, and to be worthy of trust. I am not writing this history, I am co-creating it with the people who lived it. I actively sought out an Open Access publishing method so that other people’s history could come alive and not simply be forgotten again on the bookshelves of elite university libraries. I hope that this approach, and what I can share with readers at the end of this journey, will justify the faith, trust and support with which I have been so generously endowed.