“Chapter 2 Diagnosing Difference March 2024 Edit”
Diagnosing Difference
United States Department of Justice
National Training School
Washington DC
November 8, 1966
“The boy in question is…a 17 year old Negro boy from Savannah, Georgia….it has been strongly felt by various members of the staff that he represented an extremely disturbed boy. He has been aggressive, provocative to his peers and assaultive…he has been obsessed with the thought of committing suicide…From my examination of him I would describe him as a functionally retarded boy with brain damage associated with epilepsy, with manifestations of psychosis…My diagnostic impression, at this time, is chronic brain syndrome associated with convulsive disorder with psychotic reaction. I would recommend that he be transferred to the Milledgeville State Hospital…as soon as possible. Sincerely yours, Harding W. Olson MD. Consulting Psychiatrist, National Training School for Boys.”[1]
Dr. Olson’s letter to Dr. Charles Bush, the Director of Hospital Services Branch in the Georgia Department of Public Health, reads like a veritable menu of diagnostic classifications, ranging from retardation to epilepsy to brain damage to psychosis. While the young man in question clearly suffered from traumatic brain injury as a result of untreated epilepsy, in a move typical of psychiatrists when dealing with Black patients, Dr. Olson had no hesitation in also blaming the boy for his own behavior. Olson argued that his attempts at suicide were “attention getting maneuvers” and that “he is extremely embittered and at times shows definite paranoid trends.” While Dr. Olson pointed out that the young man came from a “very deprived background with an absent father, a mother who died in 1960, and a grandmother who is limited in her resources” he also argued that the boy “is unable to see himself as having anything to do with the constant difficulty he gets into with peers and staff. Through his consistently demanding behavior he evokes a rejecting attitude on the part of others which causes him to be even more embittered. Even his suicidal ruminations tend to have a manipulative quality about them.”[2] Dr. Olson prescribed a heavy dose of Thorazine (75mg 3 times per day), as well as anti-convulsants for his epilepsy. The doctor requested that the young man be transferred to the Chatham County Jail in Savannah and then admitted via the Court of Ordinary to Central State Hospital in Milledgeville. There is a hand scrawled note on the first page that the young man was “admitted” but no further details are attached.
Dr. Olson’s letter is symbolic of many of the problems facing Black patients caught in the psychiatric network of confinement. It also speaks to some of the problems facing the historian trying to understand that experience. In Dr. Olson’s letter we see the way that multiple diagnoses are “stacked” on top of each other, at the same time as the patient is blamed for his own behavior and given a blanket prescription. We are given a glimpse into the very real social conditions that shape the patient’s experience, but in the absence of any other records this is the most we can know about this particular young man. We are also faced with the task of trying to decipher and contextualize the diagnostic miasma created by Dr. Olson. Was it standard practice to diagnose an epileptic patient with psychotic type conditions and such a large dose of Thorazine? And what did Dr. Olson mean when he said “psychotic”, because it likely did not mean in 1966 what it means in 2022? Would Dr. Olson have acted differently for his white patients? How was diagnosis used as a means for the continued confinement or description of Black disability? How much can we learn about the racialized nature of psychiatric power from an analysis of past diagnostic practices?
In this chapter, I try to untangle some of these complicated knots through an analysis of the available diagnostic and treatment data from the state hospitals in Georgia, Alabama and Mississippi. Each state kept some kind of record of diagnostic labels and rates but these records are not straightforward and diagnostic practices at all three institutions should be cause for suspicion and skepticism. Understanding diagnoses in the past is a fraught and ethically treacherous enterprise at both the level of sources and in our interpretation of them. In relation to sources, there are discrepancies between the states in the type and amount of data that was recorded and is now available. The main source of data are the annual or bi-annual reports that were compiled to report to the relevant state authorities each year, and some states like Georgia submitted complex tables breaking down diagnostics by age, race, and gender, whereas other states, like Mississippi barely reported diagnostic data at all. Georgia and Alabama created reports every year, whereas Mississippi only did so every two years, and not all of Mississippi’s reports are extant or discoverable. Alabama’s reports stop reporting complex diagnostic data from about 1960.
Mississippi’s bi-annual reports are particularly frustrating, because they do not report diagnostic or treatment data by race at all, only gender. This is a fact at once both striking and not surprising. It is not surprising to the extent that I might be tempted to argue that Whitfield didn’t bother to keep detailed records about the nature of Black illness, that it was entirely possible that there were no real attempts at diagnosis made of Black patients. It may also be the case that the physicians at Whitfield were less obsessed with the alleged racial differences in psychiatry that seemed to prevail elsewhere. The fact diagnostic categories at Whitfield were broken down by sex and age and not race might indicate that gender was a more important mediator than race when it came to actual diagnosis. The lack of reporting and detail about diagnostic categories should not be taken to indicate that Mississippi thought there was no difference along racial lines, rather that they simply chose not to record or report them publicly. The lack of diagnostic transparency could have been a consequence of the lack of psychiatric expertise at Whitfield at the time, but this erasure may also indicate a kind of deliberate obfuscation. If the performance of Jim Crow in Mississippi was predicated on a logic of benevolent paternalism then there was no need to record exact diagnoses along racial lines, and the state could then claim it treated all its disabled people with the same level of care. In the absence of details personal records, or even hospital policy records regarding admission procedures, it’s almost impossible to say anything about racial diagnosis at Whitfield. In all three states the published annual or biannual reports are only useful for an analysis at the large group level – it is not possible to analyze how any one person was committed, assessed, diagnosed, treated, cured, discharged or died.
The first section of this chapter explores the context for the development of the Diagnostic and Statistical Manual Version I (DSM-I), analyzing the ideas that informed it and considering the implications of those ideas for racialized diagnostic practices. In the second section, I focus on the implementation of the DSM-I a few years after its release in 1952 by analyzing a snapshot of data from Georgia and Alabama in 1956. I have strong caveats and even some misgivings about both the writing, and then the reading, of this section. My decision to include diagnostic data stems not from my belief in its ability to tell us anything about disease prevalence, in fact I would argue that the data cannot possibly tell us that. That is, the data that is available cannot be taken entirely at face value –just because certain amounts or types of people were recorded as being diagnosed in a certain way does not necessarily mean that they were actually diagnosed in that way, or that recorded diagnoses are even accurate. Rather my goal is to explore the ways that the newly released DSM-I was being interpreted and implemented across the three states, to tease out similarities and differences, and in that process demonstrate the way that a supposedly neutral and scientific process like diagnosis was in fact highly political. The application of diagnostic criteria reflected prevailing social ideas about race and gender, demonstrating that diagnoses were not stable criteria. But my analysis also shows that the foundation of many disparities and discrepancies in diagnosis today had their foundation laid at this early stage of DSM-related classification. Stereotypes about differences between Black and white psyches were reinforced by the application of the DSM, and thus also codified so-called differences in ways that set the scene for generations of diagnostic practice. It is not so much that DSM created race, rather it laid bare the internal racism of psychiatry right at the moment when science should have negated it, and which psychiatric science continues to repeat. The way these diagnostic ideas translated into treatment practices is the subject of the final section of this chapter.
Because of the lack of consistency or similarity from one state to another it is also not possible to provide a comprehensive comparison across the states, so the data presented here provides some snapshots into various aspects of the institutional populations, some more in depth than others. This is also the case when it comes to reporting actual treatment methods and their application. The third section of this chapter looks at prevailing ideas about and approaches to treatment in the mid 1950s, considering how available treatment modalities were operationalized differently for racial groups. The data here is not extensive: sometimes each of these states reported treatment data, sometimes they didn’t, and to find it required scouring hundreds of pages of annual reports where it was buried in a single paragraph. But there is enough to indicate that the science of psychiatry at the time enabled its own performance of the Jim Crow routine. This section of the chapter explores the way that the internal racism of psychiatry manifested in the different types of therapeutic programs that each facility developed and considers some of the implications of these discrepancies. But before we are able to analyze this data and think about what it means, we need to understand the very particular context of diagnostic practices in the mid 1950s when American psychiatry was still largely concerned with the origins of disorders as the criteria for diagnosis.
Understanding the Diagnostic Context: DSM-I and the influence of dynamic psychiatry
By the mid-1950s, all three states under study here were clearly using the Diagnostic and Statistical Manual version one, or DSM-I. DSM-I was first developed in 1952, born of an uneasy marriage between the remnants of military practice and institutional psychiatry. The need to collect data about types of mental illness had risen in the wake of WWII with unprecedented levels of what was then called “combat fatigue” or “war neurosis” and related nervous breakdown among soldiers despite the best efforts of the psychiatrists in the Surgeon General’s office to weed out perceived weaknesses through its extensive selective service program. Concerns about the stability of returning soldiers, as well as the society they were returning to, gave rise to the psy-science expert, who was now seen to hold the key to many social problems ranging from juvenile delinquency to marital problems to serious and persistent mental illness. The willingness (or necessity) of families and communities to commit family members to institutions also rose after WWII. By 1953 the total number of people institutionalized in the US for mental illness related diagnoses reached an all-time high of more than 577,000 people.[3] Some method of consistent diagnostic classification was required to at least account for the vast numbers of people being committed and to track where possible what types of illnesses were prevalent.
However, the issue of naming and defining “types of illnesses” was in itself a fraught exercise. A number of scholars have demonstrated conflicting ideological and scientific positions inherent to American psychiatry in the post-war era. [4] In many ways these conflicts represented the growing distaste for institutional work by the analytically trained psychiatrists who saw prestige, status and better money in private practice. Working with the worried well or neurotic patient was far more satisfying, rewarding and successful than the endless grind of custodial care in large, underfunded institutions where therapeutic programming for thousands of people at a time was almost impossible. In smaller private institutions or among select patient groups, psychoanalysis and psychodynamic therapies were the preferred methods. We have seen the ways these ideas informed the Black psychiatrists at Tuskegee, which reflected the latest thinking of the broader profession. But the Superintendents in the big Southern hospitals under study here were less well versed in these methods, and struggled to implement them in what were primarily custodial holding pens for many thousands of people.
Scientifically, the development of the DSM-I demonstrates the strong influence of Freudian psychoanalysis and psychodynamic psychiatry, and an adherence to the more “disease process” method of classification and diagnosis exemplified by Emile Kraepelin. This is significant for our understanding of the use DSM-I because the underlying method of creating the diagnostic categories was actually based on the supposed cause, or etiology, of illness rather than on a description of the symptoms.[5] Using something like perceived “cause” as a diagnostic tool is exactly what allowed social, political or cultural norms to pervade the “science” of psychiatry at the time. This is not to deny the importance of “environment” or trauma, but it is undoubtedly the case that “cause” was read differently according to race and gender by the majority white male physicians doing the diagnosing. For some the very fact of Blackness meant mental deficiency in the same way that the fact of femaleness meant hysteria. The psychiatric literature of the 1950s was steeped in both racialized and gendered assumptions about cause and symptomology and this inevitably played out in the way that patients were diagnosed and then treated. DSM-I remained unaltered until 1968 so its use covers the majority of the time period of this book. In the next section of this chapter, I try to highlight and then think about what the differences and similarities between diagnoses in each state indicates.
Analyzing Diagnostic Patterns
Reporting diagnosis across the three states is frustrated somewhat by the absence of racial categories in Mississippi’s data, so I present that data first on its own. In the Biennial Report ending June 30 1955 Director Jaquith reported 744 first admissions for women, and 1048 for men. While the hospital recorded diagnoses across many of the main DSM major categories, the largest category for women was Schizophrenic reactions, where 257 cases were recorded, accounting for 34% of all diagnoses for women admitted that year. The next two highest categories were ones in which women had no clear diagnosis, that is, 122 (16.3%) were listed as undiagnosed and 71 (9.5%) listed as having no disorder at all. Combined, these three categories accounted for 59.8% of all diagnoses, with the next highest being psychotic depressive reactions (47 people/6.3%); cerebral arteriosclerosis (46 people/6.1%) and manic-depressive reactions (34 people/4.5%). All other diagnoses were measured at less than 3% of the overall total. [make a pie chart]
For the men at Whitfield, the situation was quite different. In the Psychotic Disorders category, schizophrenia was attributed to 184 male patients, making up 17.5% of the total diagnoses at first admission for men, exactly half the rate as for women. The other “psychotic disorders” combined accounted for only 9% of all diagnoses, including a category called “Other” here that consisted of 29 cases attributed entirely to people under the age of 15. (This same category for women under the age of 15 was attributed to 22 people). 47 men were admitted as diagnosed with cerebral arteriosclerosis which accounted for only 4.4% of total diagnoses. [pie chart]
It is also extremely significant that more than one quarter of all the women admitted to Whitfield in 1955 were either not able to be diagnosed with something or had no obvious mental illness. There was a similar pattern for men admitted to Whitfield in the year 1955. Of 1048 total first admissions, 105 (10%) were listed as undiagnosed and 99 (9.4%) as without a mental disorder. Without access to individual patient records we cannot know if the person’s symptoms simply defied easy categorization, or whether these people were then discharged or furloughed, but this kind of data raises questions the way that admission and diagnostic procedures were implemented, and why people with no obvious mental illness were being held at Whitfield.
The impact of other social issues in Mississippi, like the prolonged state ban on alcohol, was also reflected in the diagnostic data. In the report ending June 30, 1955, 330 men were admitted under a diagnosis of alcoholism. This represented 31% of all male admissions that year and was the largest single category. In contrast, only 21 women (2.8%) were so admitted, although 22 women were also admitted for drug addiction. Mississippi remained a totally dry state until 1966. In comparison, Alabama and Georgia had ended prohibition in 1933 and 1935 respectively and this reflected in the admission data in this category. In Georgia in 1956, 134 (12.8%) white men and 17 white women were admitted with an alcoholism diagnosis while not a single case of either was attributed to Black men or women. In Alabama in 1956, only 12 white men and 1 white woman were admitted to Bryce under the diagnosis of ‘alcoholism’ and this condition was not listed at all at Searcy Hospital for Black patients. This is not to say that alcoholism was not a problem in those states, it was. But it is to say that politicians in Mississippi put pressure on the hospital to take care of specific social problems, as opposed to purely mental illness. It also indicates the way that ideas about what constituted mental illness were shaped by local politics and ideology, as well as the tendency for state governments to see psychiatric hospitals like Whitfield as the logical solution to a number of public welfare issues.
In Alabama, the link between public welfare and segregation was reinforced by and clearly represented in the Annual Reports which were separated into two sections, one containing data for Bryce Hospital (white patients) and the other for Searcy Hospital (Black patients). In 1956, the Bryce Hospital section of the report covered the first 115 pages. The Searcy report ran for a mere 41 pages. The diagnostic data was reported in complex tables that reported diagnosis at first admission under the main categories of DSM-I but unlike the Bryce section, the Searcy section only listed specific diagnoses with 1 or more patient. For 1956, Bryce recorded first admission diagnostic data for 568 white men and 519 white women At Searcy, first admission data was recorded for 236 Black men and 258 Black women. In 1956, Central State Hospital in Milledgeville, Georgia, recorded 1046 first admissions for white men, 907 white women, 356 Black men and 372 Black women. In the Georgia reports, the diagnostic statistics appeared all together in the same section but were separated into tables entitled “White Male”, “White Female”, “Colored Male” and “Colored Female”. In the following pages, I try and compare select data points together where the data is comparable in order to see what was the same and different in some diagnostic patterns in the two hospitals, and to hypothesize about what these patterns might signify.
One of the most contested diagnoses in the history of psychiatry is the category of “schizophrenia”. In the 1950s it was not precisely the same as we consider it today nor was it a direct correlation to the earlier category of dementia praecox.[6] As Horwitz has explained, DSM-I represents a kind of transitional document, linking knowledge gained in the military with broader understandings of the impact of environment and stress on mental health.[7] Illnesses that were not obviously linked to some kind of organic brain tissue damage were considered “psychogenic”, exemplified by the use of the word “reactions”. These reactions were generally considered the result of “interactions between vulnerable personalities and stressful life events, with Freudian psychodynamics, emphasizing unresolved, unconscious conflicts that arise in early childhood…therefore, the manual used the term “reaction” to characterize all of these types of disorders.”[8] The DSM itself was vague on what constituted the difference between involutional, affective, and schizophrenic reactions, and also listed 9 sub types of schizophrenic reactions, making specific diagnostics difficult even at the time, let alone for us trying to understand it 70 years later. Both schizophrenic and affective reactions were listed together in the DSM under the sentence “Disorders of psychogenic origin or without clearly defined tangible cause or structural change”, while “involutional psychotic reactions” are listed separately as “disorders due to disturbance of metabolism, growth, nutrition, or endocrine function” which was generally read as shorthand for “melancholia” related to middle age (or menopause for women).[9]
We can see these influences in the data from Alabama and Georgia, where shifts in patterns of diagnoses reveal a category in the making, subject to changes in both scientific understandings of cause and expression of mental illness, but also highly influenced by social and cultural norms. Figure 1 below sets out some of data from each state in the broad category of Psychotic Disorders. Both states reported “schizophrenic reactions” as one of three main affective disorders: involutional psychotic reactions, schizophrenic reactions, and affective reactions.
Figure 1: Psychotic Disorders Diagnosed on First Admission 1956
Diagnostic data by gender, race and state | Involutional Psychotic Reactions | Schizophrenic Reactions | Affective Reactions | Percent of Total Dx | ||||
# | % | # | % | # | % | |||
White men | Alabama | 53 | 9.3 | 144 | 25.3 | 4 | 0.7 | 35.3 |
Georgia | 2 | 0.19 | 91 | 8.6 | 141 | 13.4 | 22.19 | |
White women | Alabama | 81 | 15.06 | 216 | 42.6 | 0 | 0 | 57.66 |
Georgia | 122 | 13 | 217 | 23.9 | 74 | 8.1 | 45.0 | |
Black men | Alabama | 0 | 0 | 57 | 24.1 | 16 | 6.7 | 30.8 |
Georgia | 0 | 0 | 83 | 23 | 51 | 14.3 | 37.3 | |
Black women | Alabama | 0 | 0 | 111 | 43.02 | 40 | 15.5 | 58.52 |
Georgia | 0 | 0 | 73 | 19.6 | 35 | 9.4 | 29.0 |
Some interesting patterns emerge when comparing these diagnoses both within categories and across the states. In Alabama, when represented as a percentage of diagnoses at first admission, gender was the decisive factor in the attribution of psychotic disorders, but racial patterns were still obvious. For example, Black women were diagnosed with “affective reactions” at twice the rate of anyone else – and not a single white woman was diagnosed in this way, whereas no Black patients were diagnosed with “involutional” disorders at all. [need to explain what this is about] Schizophrenic reactions was the most widely used category for all women, accounting for 42.06% of white women’s total diagnoses and 43.02% of all Black women’s. Combined with the other psychotic disorders, this category accounted for 57.66% of all white women’s diagnosis and 58.52% of all Black women’s in Alabama. This pattern was different in Georgia: here, women were more likely to be given diagnoses from a broader spectrum across all categories, although almost half of total diagnoses for white women came from these three “psychotic disorders” categories alone (45%). For both Black and white women, and for Black men, “schizophrenic reactions” accounted for between 19 and 23 % of all diagnoses, while it was attributed to only 8.6% of first admission data for white men (compared to 25.3% in Alabama).
The most striking difference is the rate of diagnosis of schizophrenic reactions between the two states – it was twice as likely to be recorded in Alabama than it was in Georgia across all the race/sex groups. These statistics indicate a lack of diagnostic complexity in Alabama and the tendency to over or misdiagnose schizophrenia as a kind of blanket category. At this point in time, it is clear that schizophrenia in Alabama was a female diagnosis, while this was not so much the case in Georgia, where white women and Black men were almost equally likely to be diagnosed with it. But there is a striking similarity between the states which is the complete non-diagnosis of “Involutional Psychotic Reaction” for any Black patient anywhere. This one category that was considered related to metabolic changes of middle-age was not apparently considered applicable to Black patients in either state. At the very least, this indicated a disregard for either the biological or emotional complexity of Black life over the lifespan, as if those patients could not possibly experience the same metabolic processes as white people. In this pattern, the internal racism of psychiatry based as it was on unscientific notions of biological difference, became particularly clear.
The majority of other diagnoses seemed to fall into two main categories; “Chronic brain syndromes” or “mental deficiency”. Chronic Brain Syndrome consisted of multiple diagnoses but the majority of people in Georgia and Alabama were recorded under two diagnostic codes, 009-516 “Chronic Brain Syndrome associated with cerebral arteriosclerosis” (CA) and 009-79x “Chronic Brain Syndrome associated with senile brain disease” (SBD).[10] Understanding these categories is complicated because of the liminal space they inhabited between psychiatry and neuroscience, and the emerging field of “gerontology”.[11] The picture is further complicated when we try to account for the presence of Alzheimer’s Disease which was recorded under code 009-700 “Chronic Brain Syndrome associated with other disturbance of metabolism, growth or nutrition”. This code included the word “presenile” which reflects the Krapelian influence on DSM-I [add more detail from Ballenger and Horwitz here] which differentiated Alzheimer’s Disease from regular dementia associated with aging because it had been recorded in people younger than 65.[12] Even though there was significant debate in the psychiatric literature about this outdated distinction, not a single patient at Central State Hospital was diagnosed in the category associated with Alzheimer’s Disease before 1960.[13] In Alabama, the numbers in this category are extremely low: 3 white men, 4 white women, 3 Black men, and 2 Black women only were diagnosed in this category but the “age” distinction seems not to apply as these diagnoses were not confined to pre-65. Given these patterns it is impossible to say anything definitive about either the existence of Alzheimer’s Disease as a separate category or the process by which it was diagnosed.[14]
Senile brain disease is an interesting category in that it was considered a mental illness because DSM-I was still heavily influenced by psychodynamic approaches to diagnosis. As Jesse Ballenger writes “AD and senile dementia were regarded by most psychiatrists of this period not as cognitive disorders produced by biological processes within the brain, but as mental illnesses produced by psychodynamic processes occurring between an aging individual and society. So conceived, dementia was not a well-bounded disease entity.”[15] This broad, psychosocial conception of dementia is reflected in the comparative data from Alabama and Georgia, which also demonstrated a lack of clear consensus between physicians in these two states about who belonged in what category. Figure 2 below sets out the comparative data related to Chronic Brain Syndromes related to either “Cerebral Arteriosclerosis” and “Senile Brain Disease”, the two most frequently used diagnoses in this category in 1956.
Figure 2: Chronic Brain Syndromes Diagnosed at First Admission 1956 (See interactive data visualization in Tableau)
Diagnostic data by gender, race and state | Cerebral Arteriosclerosis | Senile Brain Disease | Percent of Total Dx | |||
# | % | # | % | |||
White men | Alabama | 133 | 23.4 | 10 | 1.7 | 25.1 |
Georgia | 306 | 29 | 0 | 0 | 29.0 | |
White women | Alabama | 103 | 19.8 | 14 | 2.6 | 22.4 |
Georgia | 143 | 15.7 | 131 | 14.4 | 30.1 | |
Black men | Alabama | 9 | 3.8 | 39 | 16.5 | 20.3 |
Georgia | 89 | 25 | 14 | 3.9 | 28.9 | |
Black women | Alabama | 7 | 2.7 | 38 | 14.7 | 17.4 |
Georgia | 97 | 26 | 22 | 5.0 | 31.0 |
In Alabama, there is a striking difference between white patients being diagnosed on first admittance versus the Black patients in the category of senile brain disease. The proportion of Black patients being admitted with this diagnosis was three times the amount for White patients, while the reverse pattern was true for cerebral arteriosclerosis, where only very small percentages of Black patients were diagnosed with CA. White patients, who were being admitted to the Bryce Hospital in Tuscaloosa, were far more likely to be diagnosed with CA than those being admitted to Searcy Hospital in Mt. Vernon. This overall pattern is almost completely reversed in Georgia, with some notable anomalies. White men for example were ONLY diagnosed with cerebral arteriosclerosis and none with senile brain disease at all. White women were roughly equally likely to be diagnosed with either, while Black men and women were much more likely to be diagnosed with CA than SBD in almost completely opposite proportions to the pattern in Alabama.
In the absence of clear diagnostic processes in either state it’s difficult to hypothesize what the cause of this difference might be, but I take a clue from Ballenger’s work on the thinking about senility and arteriosclerosis in the 1950s. Ballenger argues that the “traditional view that arteriosclerosis was somehow causative in all cases of dementia in old age continued to appear in the literature. Thus the diagnosis of arteriosclerosis seems to have been greatly overused through the 1960s.”[16] This was certainly the case in Georgia, where physicians at Central State Hospital were more likely to use this diagnosis for everyone except white women. The use of senile brain disease could also relate to the thinking about the cause of that disease – that it was in fact a psychosocial pathology as much as a natural consequence of old age. If, as Ballenger argues, SBD was often conceptualized as a condition related to resistance to social change, with symptoms over which the patient was believed to have some control, it makes some sense why the admitting physicians in Alabama were more likely to attribute this kind of thinking about causality to Black patients with whom they were not particularly sympathetic. It was certainly not the case that Dr. Rowe, the chief physician and assistant superintendent of Searcy, was up to date on the latest psychodynamic or social psychiatry literature, but he did have specific beliefs about the Black patients under his care, and this shaped the diagnostic and treatment approaches he adopted. As Ballenger states “other psychiatrists redoubled efforts to deal with senile dementia within the state hospitals by conceptualizing it as a treatable mental illness.”[17] One of the popular treatments used for SBD was electroshock therapy, and the frequent use of that technology at Searcy Hospital, which I analyze later in this chapter, may have some correlation with Dr. Rowe’s tendency to diagnose his Black patients with a disease perceived as a “mental illness” rather than a natural consequence of age.
Chronic brain syndrome as a category of diagnosis also needs to be considered within the overall context of care for the elderly in this decade before the advent of Medicare and Medicaid. These two categories of “chronic brain disease” accounted for around 30% of the total first admission diagnoses for all sex and race groups at Central State Hospital in Georgia. State hospitals in the 1950s were facing a crisis of care as they became dumping grounds for elderly relatives especially in states with no safety net services for the aged.[18] This was painfully evident in Georgia - the state had very few other public facilities for the care of the elderly before 1965 because it relied solely on this one large facility in Milledgeville before it began a regionalization process (see Chapter 5). However, while there is no racial difference evident in the distribution of the diagnostic categories related to old age at Central State, there is a clear race-based difference in the numbers of overall admissions in these categories. White men (306) accounted for the largest number of first admissions with “chronic brain syndromes” and white women were close behind with 284 total admissions. In comparison, there were only 119 admissions of Black women, and 102 Black men, meaning white men were admitted at three times the rate of Black men. In Alabama a similarly marked discrepancy existed – the state hospitals admitted 143 white men and115 white women with “chronic brain syndromes” but only 48 Black men and 45 Black women. There are a number of factors that could account for this discrepancy including cultural and social structures that supported intergenerational families, and communities that valued the presence of elders, as opposed to seeing them as economic burdens. As with other categories of illness, Black families were possibly less likely to voluntarily use the state hospital system if they could avoid it. But there is also the very real possibility that the Black elderly are less represented in the state hospital systems in Georgia and Alabama because they did not live as long, and that Black men in particular may have experienced other forms of institutionalization through the criminal justice system.
The other major diagnostic category utilized in 1956 was “Mental deficiency”. Mental deficiency under DSM-I was broken into two categories and the distinction between them was related to perception of cause. That is, the first type (x) was described as “disorders due to unknown or uncertain cause with the functional reaction alone manifest: heredity or familial” and the second type (y) was described as “disorders due to undetermined cause: idiopathic”. Each type had three sub types: mild, moderate, or severe.[19] The distinction between heredity and spontaneous types of mental deficiency would have been grist to the eugenicist mill but seems to have been irrelevant at the actual point of diagnosis as none of the reports from Alabama or Georgia distinguish between the two types, nor do they break down the diagnosis by sub-type. The comparative data between the two states for first admissions in 1956 is set out in Figure 3 below.
Figure 3: Diagnosis of Mental Deficiency at First Admission 1956.
Diagnostic data by gender, race and state | Mental Deficiency | ||
# | % | ||
White men | Alabama | 12 | 2.1 |
Georgia | 83 | 7.9 | |
White women | Alabama | 4 | 0.7 |
Georgia | 39 | 4.2 | |
Black men | Alabama | 17 | 7.2 |
Georgia | 33 | 9.2 | |
Black women | Alabama | 15 | 5.8 |
Georgia | 51 | 13.7 |
Again, there are some interesting differences between the states and between race/sex groups. In Alabama, there is a very clear discrepancy in the diagnosis of mental deficiency between the white patients at Bryce and the Black patients at Searcy Hospitals. The raw numbers themselves are relatively low: 12 white men, 4 white women, 17 Black men, and 15 Black women were newly admitted with this diagnosis in 1956. The discrepancy was more obvious when considered as a proportion of admissions for that year. The amount of white men at Bryce diagnosed with mental deficiency constituted 2.9% of that group’s diagnoses and 0.4% for white women, whereas at Searcy, this diagnosis accounted for 7.2% and 5.8% of all Black men and women’s diagnoses respectively. In Georgia, the numbers of people admitted in this category were higher, reflecting the larger population at Central State overall, but the greatest proportion of diagnoses were reserved for Black women: 13.7% of first admissions for Black women were classified as “mentally deficient”, 4% higher than Black men, roughly double the rate of white men, and 10% higher than white women. There was also a significant difference in the rates of mental deficiency as a diagnosis between Alabama and Georgia. In Alabama, the rates of diagnosis as “mentally deficient” were higher for all patients, and higher again for Black patients. There was a clear difference here in diagnostic practice, demonstrating the way that white physicians at Searcy and in Georgia were using different criteria for Black patients, criteria which likely reflected embedded and racist assumptions about the allegedly lower intelligence and rational capacity of the Black person.
The statistics presented in the previous pages do not represent the full diagnostic picture in either Alabama or Georgia at the end of 1956 because I have only analyzed here the categories with the greatest concentration of diagnoses. These five subcategories represent the bulk of diagnoses for women in particular, accounting for a total of 80% of all diagnoses for white women in Alabama, 79.3% for white women in Georgia, 81.7% for Black women in Alabama, and 73.7% for Black women in Georgia. The most diagnostic complexity was the purview of white men in Georgia: the categories analyzed above accounted for only 58.7% of all diagnoses. These discrepancies between the states, and between race/sex groups both within a state and compared to each other demonstrate clearly that the actual diagnostic criteria as spelled out in DSM-I were interpreted and applied differently in different locations and were both heavily racialized and gendered. They are therefore not neutral and static categories, and neither were they based on any clear scientific evidence.
Nevertheless, an analysis of diagnostic data, of any data that appears to fall along so-called racial lines, needs to be treated very carefully. If I am starting from the idea that race is a social construct (which I am), then using statistics – a tool of biomedical white supremacy – could be seen to give scientific credibility where there is none. Taken out of context, statistics like these could serve to reify the very idea of racial difference and have in fact set the groundwork for misdiagnosis today. What I am arguing here however is that these statistics, and the people who collected them, served to create racial difference as biology in the first place. My analysis here has aimed to demonstrate the way that diagnostic practices were not race neutral but were highly social and politically constructed categories and changed according to the opinions and beliefs of the diagnosing physician. These processes could be entirely different from one state (Georgia) to another (Alabama) and even between facilities in the same state (Alabama).
Yet the veneer of science lent, and has continued to lend, authority to diagnostic difference that maps alongside the socially constructed category of race, in ways that shaped and reflected both public and psychiatric ideas about psychological difference. What we are seeing in statistics like these is the making of race as a kind of subjectivity (behavior, affect, intelligence) measured as difference through psychiatry. Diagnostic categories were not simply ‘biased’ at the level of the individual practitioner but reflected broader social and psychiatric thinking about the alleged inferiority of the Black psyche. When those differences were codified by statistics in the 1950s with the advent of the DSM, they became the foundation for future belief and practice, handed down over years often unquestioned or unaltered. But these processes, just like “race” itself, are neither natural nor inevitable. In this analysis, the diagnostic data demonstrates the ways that local politics shaped diagnostics practices which reflected and perpetuated long-standing beliefs about the allegedly essential nature of the Black body-mind. Thus, racial politics which created and normalized segregation in psychiatric spaces was supported by seemingly scientific categories. Together, this creation of difference was used to justify approaches to therapy and treatment. An analysis of the way that treatments were administered to Black patients across the states in questions reveals a lot about the inherently racist assumptions of psychiatric theory and the way it was applied in the Jim Crow south. Treatment modalities varied at each hospital and in doing so they continued to demonstrate the lack of consistency or consensus in psychiatric science and revealed the ways that southern physicians individually encountered and interacted with psychiatric trends.
“All Recognized Types of Therapy”
In his introduction to the 1956 annual report from Central State Hospital in Milledgeville, Georgia, Superintendent Peacock gave an overview of the approach to treatment at this large hospital holding more than 10,000 patients. “Psychiatry, more than any other branch of medicine, is in a state of flux, because of its theoretical approach. Those of us who have devoted years of our lives to its study are often perplexed by its rapidly changing tides.”[20] The true extent of Peacock’s confusion would be revealed by a major Atlanta newspaper expose a few years later (which I explore in the next chapter) but it was already evident in the ad hoc approach to treatment and therapy at CSH. This was not in itself a problem unique to the South but it reflected the way that large hospitals ended up being a kind of dumping ground for all kinds of mental disability – from epilepsy and learning disabilities, to schizophrenia, to the dementia associated with old age. This was the case because the respective state governments were reluctant to spend money on any of the states’ “defectives” – so long as there was somewhere to put them where they were out of sight and out of mind, then the exact nature of their care, or any possibility of cure, was really beyond the interest of the state. In Georgia, this was evident by the positioning of the hospital under the purview of the “Public Welfare” department, as opposed to public health or even a special mental health branch. None of these existed in Georgia so long as Central State Hospital was the acting repository. Even if there were good intentions, the sheer size of CSH, political and community apathy, and the political economy of Georgia itself meant that the hospital barely kept people alive, let alone treated or cured.
Peacock himself was not unaware of these issues, or the way that the hospital was perceived by the public. If he was overwhelmed by the changing nature of approaches to psychiatric treatment, he was also defensive about their utilization at Central State, and simultaneously claimed that the hospital employed the latest, cutting-edge technologies in order to make the hospital something other than custodial. In the same report from 1956, he appealed to Judge Kemper, the Director of the Division of Public Welfare, to pay attention to the great work being done by Central State and the people who worked there. “Despite the fact that some of our self-appointed critics and well-meaning but misguided friends refer to the hospital as being custodial in nature only” he wrote, “living testimony in the form of numerous ex-patients who have been restored to their loved ones and their rightful places in the community refutes such claims. Records also bear out the fact that this hospital has for many years provided recreational and occupational activities for the patients; and that it has been among the leaders in state institutions in the use of insulin, metrazol, and electric shock therapy, tranquilizing drugs, and in fact all recognized types of therapy.”[21] Peacock’s comments about the different types of therapy demonstrate the way that hospitals were desperate to find and use any means at their disposal to manage the behavior of the people the state confined, and sometimes to return them to a state of well-being.
Slightly more detailed information and some insight into the ways these therapies were applied, was contained in the medical and psychology department reports from Central State Hospital. The Assistant Superintendent and Director of the Medical program, Dr. R. W. Bradford was responsible for reporting the somatic types of treatments that were administered. He did so in a descriptive summary with no breakdown of treatments by race or gender, but even so this summary shows the extent and types of interventions being used. The most common treatment was electroshock therapy as it was then called. As we saw at Tuskegee, electroshock was considered cutting edge technology at the time. Originally introduced to American hospitals in the 1940s?? it became a highly potent tool for managing patient symptoms.[22] Its use and intent, as we will see later, was not always therapeutic when it came to Black patients, but at this point in time its ability to modify patient behavior in large institutions made it particularly valuable. In 1956, Dr. Bradford wrote “we continue to make extensive use of electric shock therapy with good results”, reporting that “three thousand, nine hundred and thirty-four (3,934) patients were treated and thirty thousand, seven hundred and twenty-six (30,726) treatments were given.” [23] He expanded on the “good results” and supposed efficacy of ECT stating that “eight hundred and forty-nine (849) patients were reported as having been restored; two thousand, four hundred and twenty-three (2,423) were improved and six hundred and sixty-two (662) as unimproved.” There is no indication of what constituted “improved” or not, but generally speaking at the time a patient undergoing ECT would have been considered “improved” or “recovered” if the symptoms associated with severe delusions, aggressive or extroverted behavior, or depression were modified. (refs). Without detailed and individual reports it is not possible to tell which groups of people specifically were being given ECT or for what behavior or diagnosis, but 3934 patients was more than one third of the total inpatient population of 11, 701. It was also slightly less than the total number of all patients, not just first admissions, classified as schizophrenic (4275). It is impossible to tell whether ECT was being used as a therapy specifically for the treatment of schizophrenia (as it was originally intended) or rather for the behavioral symptoms that made people hard to manage regardless of their specific diagnosis. The most striking part of this scenario however, is the sheer volume of treatments. If 30,726 treatments were administered in the single year between July 1955 and the end of June 1956, then an average of 84 treatments occurred every single day (counting weekends, although I suspect they didn’t perform them on Sundays.) This equates to roughly 10.5 treatments per hour (working on an 8 hour day). In real time, I am sure it was more than this. This is an astonishing amount of treatments, suggesting a factory like approach and little concern with sedation or after care. Although there is no detail about the processes by which ECT was administered at Central State Hospital, this image from the Atlanta Journal Constitution from 1950 shows a group of student nurses holding down a patient while a head nurses administers the treatment from what looks like a small mobile machine. https://georgialibraries.omeka.net/s/central-state-hospital/item/882
While I have no doubt that nurses were entirely capable of administering ECT, it’s notable that there is no physician in sight. These practices raise many questions about the logistics of ECT administration, the safety of patients undergoing it, and the care of patients post-treatment. There are also no photos, or any other direct evidence, about the way ECT was administered to Black patients in this hospital.
Two other highly dangerous and quickly discredited somatic therapies were in use at CSH in the mid 1950s: insulin coma therapy and metrazol shock. Both ECT and Metrazol shock were designed to mimic the after-effects of an epileptic seizure where the patient might experience a reprieve from delusions or heightened anxiety and appear relatively calm and lucid. Both Metrazol and electronic shock were performed without sedation and resulted in broken bones, and as we now know, broken memories and affect.[24] Insulin coma therapy required the administration of excessive amounts of insulin in order to create a diabetic coma (again aimed at relieving the symptoms of schizophrenia) and in 1956 at CSH it “was used on two hundred and thirty-nine (239) cases, receiving a total number of one thousand and seventeen (1,017) treatments.”[25] Insulin coma therapy was much more nursing care intensive as it involved complete bed rest and intravenous administration. Both insulin and Metrazol were discredited by the early 1960s as completely ineffective and dangerous, but there was plenty of discussion within psychiatric circles during the 1940s and 1950s about the efficacy and safety of these technologies (need refs here!). There is no evidence that physicians at Central State were aware of or concerned about these problems.
Eventually Metrazol and insulin were also supplanted by the arrival of psychotropic drugs like Thorazine which made its entry to the US hospital market around 1954. First synthesized in France as chlorpromazine (still its generic name) in 1951, it was distributed to large hospitals in bulk while still technically experimental from about 1952. (check/refs) It was not officially approved by the US FDA until 1955 but was already well in use along with other major tranquilizers like lithium. Another major tranquilizier, Haloperidol (Haldol) was in development at the same time but was not approved in the US until 1967 (check all your facts, dates and add references here. Also was it used anyway?). Again the records here are frustrating. Exact names of drugs administered are not recorded in the CSH annual report, (what about total drug budget) but Dr. Bradford’s summary suggests they were extensively used as early as 1956. “We have used to good advantage the tranquilizing drugs” he wrote. “Three thousand, two hundred and eighty-two (3,282) patients were treated and we are well pleased with the results from their use. Of this number two hundred and thirteen (213) were reported as having been restored; two thousand, four hundred and seventy-four (2,474) were improved and five hundred and ninety-five (595) as unimproved.” The overall rate of improvement from drugs was about comparable with that reported as improved from the use of ECT, but the rates of cure from ECT seemed much higher. For example, Dr. Bradford’s numbers suggest that 21% of patients administered ECT therapy were reported as cured or restored as opposed to only 6% of the patients who were administered tranquilizers. This discrepancy possibly signifies the different ways that efficacy was being measured as much as it reflects the more potent and noticeable effect of ECT over the new drugs that were still largely experimental. Significantly, there is absolute silence on the racial or gender breakdown of the use of any of these somatic therapies, so it is impossible to tell their efficacy, let alone their usage, among the Black patients at CSH.
There is one particularly telling piece of information that does say something about the highly racialized therapeutic environment at Central State Hospital in the 1950s. Apart from the medical department who oversaw the physical aspects of patients’ well-being as well as the somatic therapies, CSH was home to a psychology department. It was a new department, only 5 years old at the time, and was headed by John T. Rowell, Chief Clinical Psychologist. Rowell was committed to implementing a psychotherapy program and reported that he and his small team had performed 919 psychological tests (including the Rorschach and Bender-Gestalt tests) and that they had 15 current patients in individual psychotherapy and 182 participating in group psychotherapy. Rowell also reported on a “psychotherapy activation program”. The goal of this program was to “create a therapeutic atmosphere in which more concentrated psychotherapy could be given” and it consisted of group activities, music therapy, and informal psychotherapy.[26] Rowell was quick to differentiate this from recreational or occupational therapy, explaining that “these activities were not designed for entertainment but directed toward therapeutic goals of group participation and have resulted in arresting the regressive process for most patients in those settings where used.”[27] Significantly, the settings in which this kind of activity was taking place at Central State Hospital were in the white sections only. Rowell reported that the psychology department had seen 210 white male patients, and 315 white female patients over the past five years, and that the success of the psychoactive therapeutic program was “an accomplished fact on the white female service.”[28] While they hoped to make more progress on “the other services” at this point it seems that the priority for psychotherapy was white women, revealing the racial and gendered assumptions inherent to the practice. Not only were Black patients apparently not considered suitable for or worth including in the program, it was also likely that the emphasis on white women reflected the prevailing idea that white women who were institutionalized were more likely to be suffering from environmentally related neuroses rather than organic or psychotic illness and were more likely to respond to “talking therapy”.[29]
Some of these same assumptions and patterns are evident in Alabama at the same time, but there are some differences worth noting, including the heavily racialized use of ECT. Because Alabama ran two entirely separate facilities, one dedicated to white patients and one to Black, the racial comparison is much more overtly reported and strikingly obvious. Superintendent Tarwater was quick to report all the cutting-edge latest technologies in use at Bryce, at the same time as he acknowledged that the system was overcrowded and underfunded. In the same way that Superintendent Peacock was in Georgia, Tarwater was defensive about the perception of his hospitals as purely custodial and spent a great deal of effort explaining to the Governor and the Board of Trustees the need for more money so that a more active therapeutic regimen could be implemented. “With money appropriated, together with receipts from other sources, farm and land sales”, he wrote, “we have endeavored to improve the care, treatment and living conditions of patients in several ways, specifically by the addition of personnel who are active in the treatment and rehabilitation of patients.”[30] Tarwater reported fairly extensively on the use of the new drugs, with more detail than was evident at Central State in Georgia. For example, he reported the use of both Serpasil and Thorazine, and explained that he was given large supplies of both drugs directly from the pharmaceutical companies. Thorazine came directly from Smith, Kline and French and cost about $10 per month per patient. Most of the people prescribed Thorazine had families who could pay for the treatment.[31] Serpasil, or reserpine, was different, and not in use in Georgia as far as I can tell. Now discontinued, serpasil was technically a treatment for hypertension but also had known sedative effects. Some psychiatrists at the time were experimenting with its use for psychiatric disturbance. In an article from 1955, J.D. Glynn reported its use as a treatment for “psychomotor excitement” arguing that while barbituates and ECT were widely used, “it is a common experience, however, that even after adequate and efficient treatment a number of patients either do not respond satisfactorily to these measures or exhibit a tendency to relapse fairly rapidly. Rauwolfia serpentina ("serpasil"), a new drug, is of undoubted value in the treatment of these cases."[32] Manufacturer Ciba supplied this experimental drug directly to the Alabama state hospitals, and Tarwater used it for indigent (non-paying) patients only.[33]
There was only a nascent psychology program at Bryce Hospital in Tuscaloosa, with one full time psychologist (Waters C. Paul) and one part time PhD prepared clinical psychologist Dr. D. A. R. Peyman who was finally appointed full time in 1956. Two other part time psychology assistants and an administrative assistant were also hired that year. In 1956, that department administered 6,227 psychological tests to both patients and potential staff, compared to 1017 conducted in 1953, its first year of operation. Their active therapy program was limited however. Dr. Peyman reported that “there were several psychotherapeutic groups conducted this year. One group consisted of patients from the Ladies Receiving Building and another of older chronic schizophrenic patients, and both were carried for seven or eight months. There has also been individual psychotherapy for patients referred to this department by their hospital physicians.”[34] Peyman reported about his attempts at using group psychotherapy in a small group of 32 white women diagnosed with schizophrenia in the journal Group Psychotherapy in 1956. In this study he measured IQ scores before and after treatment and found that the greatest improvement (of only two points) occurred in the group who underwent both electroshock and the group therapy program.[35] In the same way that Dr. Rowell had in Georgia, Dr. Peyman hoped that an expanded budget would allow his department to expand and develop an active research program (include the Georgia doctor publications above).
There was no mention of any kind of psychology or psychotherapy program for Black patients at Searcy Hospital in Mt. Vernon. Section II of the Annual Report is a mere 30 pages (compared to the 130 plus for Bryce Hospital) and devoted entirely to activities at Searcy the Black patients’ hospital in Mobile. Here there was no psychology department at all, and no report on the use or distribution of drugs. If Tarwater was sending drugs down to Searcy there is no record of it here. The main “therapeutic” technology in use at Searcy was electroshock therapy, and a comparison of the data about its use there with the same data from Bryce in Tuscaloosa is set out in Figure 4 below[36].
Figure 4: Use of Electroshock Therapy in Alabama State Hospitals 1956
Male Patients | Female Patients | |
Bryce Hospital Population (white) (including on trial) | 2385 | 2612 |
Number of patients treated | 609 (25.5%) | 548 (20.9%) |
Number of treatments given | 10026 | 2997 |
Average treatments per patient | 16 | 5.4 |
Searcy Hospital Population (Black) (including on trial) | 1390 | 1649 |
Number of patients treated | 321 (23.09%) | 939 (56.94%) |
Number of treatments given | 3210 | 5348 |
Average treatments per patient | 10 | 5.6 |
The Annual Report for Bryce Hospital in 1956 did not include a breakdown of all patients in the hospital by diagnostic category, only for first or readmissions that year, so it’s not possible to record here the correlation between ECT use and the size of the total ‘schizophrenic’ population. Nevertheless, some discrepancies are striking. While use of ECT was reserved for only 25% of the white men at Bryce and 20% of the white women at Bryce, white men experienced the highest average treatments, with 10,026 treatments among 609 patients equally an average of 16 per person, which is much higher than any other patient group, and exceeded the usual recommended treatment course of 10 per patient (ref). Most obviously problematic at Searcy however was the use of ECT for Black women. While the Black men were likely to be given more treatments each on average (10 compared to the women’s average of 5.6), the percent of men being subjected to electroshock was 23%, less than the rate for white men. But the use of ECT among Black women was more than twice the amount among white men again. More than 56% of ALL the women at Searcy were subjected to ECT in the year ending September 1956, with an average of 5.6 treatments per person (below the recommended therapeutic dose). This is a stark and telling difference, it’s hard to read or report it without a sense of utter outrage at the thought of the violence and terror this practice must have incurred among the Black women at Searcy all of whom either experienced ECT or knew someone who had. Searcy also reported diagnostic category only at the time of first admission, and in this year administrators diagnosed schizophrenia among 57 new men and 111 new women so the use of ECT for women (double that of the men) also tracks with the rate of diagnosis (double that of the men).
The frequency of ECT administration in Alabama was much less than in Georgia: at Bryce 13,023 total treatments were spread over 365 eight-hour days which averaged to about 4.4 treatments per hour. Apart from the population being much lower than in Georgia, I suspect this is also because the wards at Bryce were much closer together and there was less likely to be multiple machines and multiple operators. At Searcy the rate of ECT per hour was much less again. 3049 total treatments administered over a year equates to about 8.35 treatments per day, or one per hour. Again, this is in the context of a lower population (3039 total) but it also likely reflects the reality of the staffing at Searcy which consisted of only the Superintendent Dr. Rowe and 3 assistant physicians with a team of largely untrained attendants listed as “the nursing service” with no RN in charge. The lack of diagnostic complexity discussed above translated to a direct lack of therapeutic complexity for Black women in Alabama. Searcy had no psychology department and no visiting or consultant psychologists, and no attempts at psychotherapy were reported here at all.
The brevity and scarcity of the Biennial reports from Whitfield Hospital in Mississippi make it almost impossible to present a true picture of therapeutic practices there. In his summary at the beginning of the report for 1955-1957 Director Dr. Jaquith summarized the impact of the new tranquilizing drugs and their cost for the hospital. “During the past biennium”, he reported “there has been a tremendous upsurge in the field of psychiatry and the use of new tranquilizing drugs. These drugs are a valuable implement in the treating of the mentally ill. We have used these drugs widely and as they are quite expensive this has caused us to dig deep into the General Fund to purchase drugs which will give the patients the benefit of every modern treatment.”[37] Jaquith noted that “one of our neighboring states” had had an emergency legislative meeting to approve an increased state appropriation for psychiatric drugs, whereas Mississippi had not done so. This meant that Jaquith was paying for them direct from his own budget. Given how few paying patients the hospital had this was a significant outlay, tripling his expenses for the two years of 1955 and 1956. He argued that the expense was necessary because not only did the hospital owe it to the patients to provide them with access to the latest technologies, but the drugs were also proving effective and enabled him to discharge patients at a faster rate.[38]
Most of the rest of Jaquith’s summary from the 1957 report detailed the struggle he had to retain trained psychiatric staff in the absence of a larger psychiatric program in the state, reflected in the fact that the new University of Mississippi Medical School in Jackson had no psychiatric beds and students there rotated through Whitfield for 12 weeks at a time. Jaquith reported that Whitfield been approved for a one-year residency program and he hoped this would bring more trained staff to work at the hospital.[39] Jaquith frequently lamented the fact that “Mississippi suffers from an acute shortage of trained people to treat the ever increasing number of mentally ill. There are very few psychiatrists practicing in the state of Mississippi at a private practice level. To serve more than 2,000,000 Mississippians, there are approximately thirty psychiatrists. Like all state mental hospitals, this hospital lacks many psychiatrists, psychiatric social workers, psychiatric nurses, and other top
personnel. We have only been able to maintain a skeleton crew of trained people.”[40] In the 1957-1959 report, Jaquith included a summary of “Methods of Treatment” which listed electroshock, hydrotherapy, group therapy, Antabuse therapy, drug withdrawal therapy” as well as the widespread use of new drugs.[41] Antabuse was (is) a drug designed to treat alcoholism, a major problem for Whitfield. Interestingly, Jaquith noted that the use of Insulin Shock therapy had been discontinued at Whitfield and in most other places from 1956 (except for Milledgeville apparently) and was no longer a credited form of therapy, not least because it was time and labor intensive.[42] Yet Jaquith did report on the occasional use of prefrontal lobotomies, which “from time to time…are performed by consulting neuro-surgeons. These pre-frontal lobotomies are not done until every form of acceptable therapy has been tried and evaluated.”[43] At no point in any of these official reporting documents (or anywhere else I have been able to find) does Whitfield Hospital list any cross-referencing data related to the administration, distribution, or expense of actual treatments.
At the same time, Whitfield struggled to develop and maintain a psychology department, which waxed and waned depending on the availability of staff. Some attempts at psychotherapy had been made, including a group therapy program run by a resident and a short lived “exit group” on the White Female receiving ward, but these programs were difficult to sustain due to the time and personnel required.[44] It seems a given that these programs would only apply to the white patients, but there is some evidence of attempts to provide therapeutic services for Black patients in other records. As was evident in the employment of Dr. Washington as the first Black physician in 1955, Jaquith demonstrated some slightly progressive tendencies when it came to recognizing the importance of racially concordant care, especially in his attempt to make Whitfield something other than a series of holding cells. In the patient newsletter, The Whit, which ran for only a few years from 1951 to about 1955, “the colored service” section reported on the presence of a young psychologist from Tougaloo College, Dr. Matthew Burks. Dr. Burks was at Whitfield for about a year from 1951-1952, and worked to institute a more rigorous psychological testing program and other activities that would “contribute in bringing the colored ward in line with the progressive ideas of Dr. Marshall, Dr. Jaquith and Dr. Daly.”[45] (Marshall was the superintendent of Negro service and Daly was the Chief Clinical Psychologist for the whole hospital). Burks continued to report briefly in The Whit, writing in July of 1951 that “my activities at present include: testing patients, obtaining case histories, conducting individual and group therapy, and other forms of therapeutic activities.”[46] Burks believed in the importance of an active program aimed at rehabilitation and recovery in which people could be returned to their communities, and hoped that the work he was doing at Whitfield, which included public outreach, might go some way to educating the Black public about the importance of mental health, and to reduce the stigma around mental illness. [give a quote here?]
That same year, Whitfield played host to its first series of student interns, also from Tougaloo College, as part of a class on psychopathology. This relationship between Tougaloo and Whitfield represented a genuine attempt to better educate Black students about mental health and psychiatry for the benefit of their communities. As student reporter Tommie Anderson wrote in The Whit, the students had learnt that “mental illness is like physical illness. It has its diagnosis, prognosis, and treatments just as is found in physical illness.” He reported that their time at Whitfield, and the emphasis on public mental health, had “inspired some who were interested in psychology, to help others of their race.”[47] The program for training Black students and employing Black staff was evidence of some attempt at Whitfield to bring services for Black patients into better alignment with those for white, and for a short while this may have been partially successful. At the end of the first report from this class, an unnamed person wrote “the colored hospital feels that its functions and services are a matter of personal pride and any observer will truthfully say that he can find no other hospital, white or colored, possessed of better administration or morale.”[48] Of course, whether this was how patients themselves experienced Whitfield is another matter, and I try to unpack some of that in the next chapter.
Despite various issues with the official records, and the challenges of building comparisons across three states, the data presented in this chapter paints a picture of large hospitals struggling to function as anything more than custodial. Administrators and staff knew that better approaches were possible but were hampered by the refusal of conservative state legislatures to spend any more than was necessary on the states most undesirable people. When this general apathy and neglect intersected with existing racial attitudes and structures like segregation, amplified by the already existing internal racism of psychiatric practices like diagnosis, the situation for Black patients was dire. Superintendents tried to use any technology at their disposal to reduce their population size and control inpatient behavior (whether this actually cured people or not) and this meant that approaches to diagnosis and treatment were often ad hoc if not downright abusive. When these practices occurred in deeply racially divided spaces then the opportunity and circumstances for dismissive, disrespectful, and neglectful care were rife.
Disparities in diagnostic practices were supported by prevailing psychiatric ideas which held that there was something intrinsically different, and therefore inferior, about the Black psyche. [do you need to expand this here drawing on the things written by psychiatrists etc? or you can refer people to the theory chapter?] This led to a lack of diagnostic complexity for Black patients, and an over reliance on the general, poorly understood, category of “schizophrenia” especially for Black women. In this moment, in this first application of the DSM-I, we can clearly see the way that prevailing attitudes were codified into diagnostic practice which became scientific knowledge, handed down almost unaltered into the present. And where Black patients were more isolated, as in the case of Searcy Hospital in Alabama, the hostility and violence of white supremacy was unleashed against the Black patient through an over reliance on electroshock therapy, surely one of the most terrifying of medical technologies ever invented. But electroshock and tranquilizing drugs were not the only ways of keeping patients quiet and under control. The most prevalent “therapeutic” technique in all of these spaces was called “occupational therapy”, and for Black patients this mostly took the form of intense, involuntary, and back breaking manual labor. The way that the use of patient labor was disguised as occupational therapy and constituted a particular performance of the Jim Crow routine in the context of Southern society, is the subject of the next chapter.
Dr. Harding Olson to Dr. Charles Bush, Director of Hospital Services Branch, Department of Public Health, Atlanta Georgia. November 8, 1966. RCB-29713, Public Health – Mental Health – Director’s Administrative Files, Central State Hospital Complaints, 1966-1969, Georgia State Archives, Morrow GA. ↑
Ibid. ↑
Morton Kramer, “Long Range Studies of Mental Hospital Patients: An Important Area of Research in Chronic Disease,” The Milbank Memorial Fund Quarterly 31, no. 3 (July 1953): 253–64. ↑
See for example Gerald N Grob, Mental Illness and American Society (Princeton NJ: Princeton University Press, 1983); Nathan Hale, The Rise and Crisis of Psychoanalysis in the United States: Freud and the Americans 1917-1985 (Oxford: Oxford University Press, 1995); Anne Harrington, Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness (New York: Norton, 2019); Joel Braslow, Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century (Berkeley: University of California Press, 1997); Richard Noll, American Madness: The Rise and Fall of Dementia Praecox (Cambridge MA: Harvard University Press, 2011); Allan V. Horwitz, DSM: A History of Psychiatry’s Bible (Baltimore: Johns Hopkins University Press, 2021). ↑
Horwitz, DSM: A History of Psychiatry’s Bible. ↑
Noll, American Madness: The Rise and Fall of Dementia Praecox; Harrington, Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness; J Metzl, The Protest Psychosis: How Schizophrenia Became a Black Disease (Boston MA: Beacon Press, 2010). (add other sources) ↑
Horwitz, DSM: A History of Psychiatry’s Bible. ↑
Horwitz. ↑
DSM-I (1952) p5. See also Horwitz. P112. ↑
Of note here is the fact that “Chronic Brain Syndrome: Convulsive Disorder associated with epilepsy” was not recorded for a single patient in Georgia in 1956- in fact it does not appear until 1960, and only for a total of 14 white patients and 12 Black patients in Alabama in 1956. ↑
Jesse Ballenger, Self, Senility, and Alzheimer’s Disease in Modern America: A History (Baltimore MD: Johns Hopkins University Press, 2006); Jesse Ballenger, “Beyond the Characteristic Plaques and Tangles: Mid-Twentieth Century U.S. Psychiatry and the Fight Against Senility,” in Concepts of Alzheimer’s Disease: Biological, Clinical, and Cultural Perspectives, ed. P.K Whitehouse, K Maurer, and Jesse Ballenger (Baltimore MD: John Hopkins University Press, 2000), 83–103. ↑
Thank you to Dr. Ballenger for his help with clarifying this pattern. Personal correspondence, March 11, 2024. ↑
See Ballenger for references to the debates within the psychiatric literature. ↑
Obviously, the diagnosis of AD was further complicated by the lack of testing procedures before the 1990s, so diagnosis was only possible post-mortem (check these dates). See Knopman DS, Petersen RC, Jack CR Jr. A brief history of "Alzheimer disease": Multiple meanings separated by a common name. Neurology. 2019 May 28;92(22):1053-1059 ↑
Ballenger, “Beyond the Characteristic Plaques and Tangles: Mid-Twentieth Century U.S. Psychiatry and the Fight Against Senility.” P84 ↑
Ballenger. P87 ↑
Ballenger. P87 ↑
Gerald N Grob, From Asylum to Community: Mental Health Policy in Modern America (Princeton NJ: Princeton University Press, 1991). ↑
DSM-I (1952) p5. ↑
Superintendent Peacock, CSH Annual Report 1956, p9-10 ↑
Superintendent Peacock, CSH Annual Report 1956, p8 ↑
Jonathan Sadowsky, Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy. (Taylor and Francis, 2016); Braslow, Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century. ↑
Dr. Bradford, Medical Department Report, CSH Annual Report, 1956, p18 ↑
Sadowsky, Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy.↑
Dr. Bradford, Medical Department Report, CSH Annual Report 1956, p19 ↑
John T. Rowell, Psychology Department Report, CSH Annual Report 1956, p98 ↑
Ibid. ↑
Ibid. p99 ↑
Jonathon M Metzl, Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs. (Durham NC: Duke University Press, 2003); Laura D. Hirshbein, American Melancholy: Constructions of Depression in the Twentieth Century (New Brunswick, New Jersey: Rutgers University Press, 2014); Ranjana Khanna, Dark Continents: Psychoanalysis and Colonialism (Durham, London: Duke University Press, 2007); Walter Adams, “The Negro Patient in Psychiatric Treatment,” American Journal of Orthopsychiatry 20, no. 2 (1950): 305–10; Janet Kennedy, “Problems Posed in the Analysis of the Negro Patient,” Psychiatry 15, no. 3 (1952): 313–27. Check some of these ↑
Superintendent Tarwater, Annual Report to the Board of Trustees, 1956, p8 ↑
Ibid, p9 ↑
J.D Glynn, “Rauwolfia Serpentina (Serpasil) in Psychiatry,” J. Neurol. Neurosrug. Psychiat. 18 (1955): 225–27. ↑
Tarwater, Annual Report to the Board of Trustees, 1956, p8 ↑
Dr. Peyman, Psychology Department Report, 1956 p94-95 ↑
D.A.R. Peyman, “An Investigation of the Effects of Group Psychotherapy on Chronic Schizophrenic Patients.,” Group Psychotherapy IX, no. 1 (April 1956): 35–39. ↑
Data comes from main table of patient population for 1956 Annual Report p13 ↑
Mississippi State Hospital Biennial Report 1955-1957 p7. ↑
Ibid ↑
Ibid p16-17 ↑
Mississippi State Hospital Biennial Report 1957-1959 p9 ↑
Ibid, p56 ↑
Ibid, p56 ↑
Ibid, 56 ↑
Ibid, p36 ↑
The Whit, Vol 1, No 7, April 1951 p26 MDAH. I use The Whit more extensively in the next chapter to tease out some themes related to every day life at Whitfield in more detail. ↑
The Whit, Vol 1, No 10, July 1951, p21. ↑
The Whit, Vol 1, No 9, June 1951, p24. ↑
The Whit, Vol 1, No 7, April 1951, p25. ↑
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