Mental Health, Malpractice, and Marginalization

Joanne Freeman:
On today’s episode, we’re going to look at a few examples of racial health gaps throughout American history.

Brian Balogh:
You’ll hear how tuberculosis disproportionately affected Native Americans in the early 20th century, and what the government did to combat it.

Joanne Freeman:
We’ll discuss a court case in the 1970s about a change in reproductive justice for Latino women.

Brian Balogh:
As our current pandemic serves is a brutal reminder of this country’s racial health disparities, it’s important to recognize that a difference in health outcomes doesn’t only pertain to one’s physical well-being. Mental healthcare has long been marred by mistreatment and detrimental diagnoses for patients of color.

Kylie Smith:
The most striking example is really around schizophrenia. At the moment, the data suggests that schizophrenia is diagnosed six times more for black men than it is for whites. That is different to what it used to be in the past, and it also means that depression is under diagnosed in African Americans.

Brian Balogh:
Kylie Smith is an associate professor for nursing in the humanities at Emory University in Atlanta. She’s also the author of the forthcoming book, Jim Crow in the Asylum: Psychiatry and civil rights in the American South. She says mental healthcare in the United States has been plagued by racism for centuries.

Kylie Smith:
I think the most striking example of the way that psychiatrists and physicians were thinking about racial difference, especially during slavery, comes down to one particular doctor who’s quite famous in the history of medicine, infamous really, Samuel Cartwright, who was actually from Virginia, but he wrote in 1851, in the New Orleans Journal of Medicine, a really quite long and detailed article about differences between the African American and the white body and also mind.

Kylie Smith:
He talked about how the African American person was basically designed for slavery because they had a great a bend in the knee. When you read it, you just think this is ridiculous, how could this be possible that anyone would think this way? But he’s really reflecting these broader ways of thinking that are trying to justify slavery, and really to justify the position of the African American as subservient, and not quite human. You really see that in his thinking about the psychology of the psyche, I guess of the African American, where he will talk about them being much more childlike, they do better under protection, they should be kept submissive, because that’s their natural state.

Kylie Smith:
With that, you have this idea that they’re not as well developed psychologically. He invented a few interesting mental illnesses in particular, one condition that he called drapetomania, which was the illness of running away from slavery. You can see in this kind of thinking, this kind of circular logic that makes the behavior of African Americans pathological.

Brian Balogh:
How does that kind of thinking carry into the treatment inside asylums after the Civil War?

Kylie Smith:
There are so many things happening in that post Civil War period around the construction of new asylums. As those asylums begin to get built in more places in the 1860s and 1870s, they would take in African American patients, small numbers to start off with, but it began to increase and they were segregated. At that point in time in American psychiatry, the main prevailing therapeutic approach was what we call moral therapy or moral treatment. It really came out of Europe and the UK, this idea that if you put a patient, a distressed or excited or anxious patient, you would need to take them away from their environment and put them in some kind of idyllic countryside estate.

Kylie Smith:
A lot of these institutions look quite imposing and quite beautiful. But also because they were rural, they also meant that people could be put to work. Moral therapy did rely on this idea that people should be kept busy. That’s fine if you’re a white middle class lady, and the treatment that you’re going to be given is, you could sit in a nice room and do your tapestry, or you could maybe do some gardening. But what we have found that for African American patients, moral therapy translated to work on the farm.

Kylie Smith:
There’s very little difference between how people were worked on a plantation and how they were worked on an asylum farm. That is the main form of treatment that African American men were given and the women were put to work in the laundry and the kitchen, just as how they had been on the plantation.

Brian Balogh:
Did this persist throughout the Jim Crow era, which is to say the whole first half of the 20th century in the south, in the United States?

Kylie Smith:
Yes, it did. It persisted for quite some time. It persisted in at least two places that I’m aware of until the late 1960s. It really was about… Especially in places where a separate facility had been built for African American patients. It could really be out of sight out of mind. People were working on farms and working to the extent that the farm was providing all of the food for the hospital, and not only food for the hospital, but surrounding neighborhoods and was making a profit for the hospital.

Brian Balogh:
Could you describe the line between determining that someone had engaged in criminal behavior and, on the other hand, mental illness, especially as it was applied to African Americans?

Kylie Smith:
That line between mental illness and criminalization I think is really a very fine line historically and current. I think, historically speaking in the emancipation and reconstruction period, I think it was very easy for African American behavior to be considered criminal before it was considered a mental illness. Whereas with a white person, there might be some kind of empathy, or maybe they’re traumatized, but for a black person, the first port of call would be the police.

Kylie Smith:
A lot of that is behavior. I think that comes out of emancipation and reconstruction. People are traumatized, people are trying to find a home, trying to find some kind of work, trying to make sense of their new lives. It was very easy for the systems that were in place to classify African American behavior as criminal.

Martin Summers:
Prior to emancipation, the first half of the 19th century, the psychiatric consensus held that black people were relatively immune to insanity.

Brian Balogh:
Martin Summers who’s also researched the history of black mental healthcare, he’s the author of Madness in the City of Magnificent Intentions: The History of Race and Mental Illness in the Nation’s Capital. He says psychiatrists in the 1800s said African Americans were actually immune to insanity because of physiological and cultural reasons.

Martin Summers:
Physiologically, it was thought that black people did not have advanced enough nervous systems to deteriorate in the first place. Then also, because they were slaves or the overwhelming majority of black people in the United States were slaves, there was this idea that they were protected from the kinds of stimuli that might be exciting causes for insanity such as stress, or too much education, right? Because, again, they essentially had all of their needs taken care of by their masters.

Martin Summers:
After emancipation, when all of a sudden you have an increasing number of African Americans being admitted into asylums, there is an attempt to explain this increase in rates of insanity. Psychiatrists basically point to emancipation itself, freedom itself as driving black people insane because again, they did not have the cognitive capacity, or the emotional ability to actually survive in society as free willed subjects or subjects with free will. That in itself was leading to their mental breakdown.

Brian Balogh:
Both Martin and Kyle Smith know the discrepancy in how psychiatrists treated white and black mental health patients wasn’t isolated to the deep south. Martin has researched the story behind St. Elizabeths Hospital in Washington, DC.

Martin Summers:
St. Elizabeths Hospital was founded in 1855. What makes St. Elizabeths very interesting is it’s one of the few Southern asylums that actually admits both white and black patients from very early on. Really from the day it opened, it admitted black patients, but it did so against this larger backdrop of a psychiatric consensus that pretty much held that African Americans themselves as “primitive peoples” were relatively immune to insanity.

Martin Summers:
Just as you have this hospital opening up and admitting, “colored insane” they’re doing so at a time when most physicians thought that black people were relatively immune. From the very beginning, insane African Americans constituted a problem for the psychiatrists at St. Elizabeths.

Martin Summers:
In some ways racial segregation, there was a therapeutic rationale to racial segregation itself. For white patients, that environment that they needed to be in needed to essentially be racially homogenous, because it was thought that being in an integrated environment might cause them stress. They also should be in an environment with people who were suffering similar diseases as them. But that kind of rationale didn’t apply to black patients. For instance, black patients, there wasn’t an effort to separate a black person who was diagnosed with melancholia from say a black person who was diagnosed with epilepsy. Although, there was very much an effort to separate white melancholics from white epileptics.

Martin Summers:
The idea that an insane person needed to be removed from the environment that was causing them emotional and psychological stress didn’t apply to black patients to the same extent as it applied to white patients.

Brian Balogh:
These conditions often went unchallenged throughout the first half of the 20th century. However, Kylie Smith says that things started to change in states like Alabama during the 1960s. That was when civil rights activists, lawyers and federal agencies started to look more into conditions of mental health facilities, such as Searcy Hospital in Mobile, Alabama.

Kylie Smith:
Health Education and Welfare launched an investigation into that hospital and they sent an inspector down in 1967. She said, “It was like something out of a Kafka play.” Those are her words, that it was really the most horrible thing she’d ever seen, and that Searcy Hospital was being run like a plantation, were her words.

Brian Balogh:
In the late 1960s, civil rights advocates brought a case before district court judge named Frank Johnson challenging Alabama segregation policies in mental health hospitals.

Kylie Smith:
It was obvious to him right away that it was not medically justified. There were a bunch of psychiatrists who were called to testify and they all said there is no medical justification for segregation, that it doesn’t harm black or white patients to be treated together. Interestingly, that there is no difference in the way that black or white mental health should be treated. One psychiatrist even said, “I don’t believe that there is any difference between the black and the white brain, that the difference is that we see are a result of social inequality, not a lack of intelligence.”

Kylie Smith:
It didn’t take Frank Johnson long to decide that segregation in the state psychiatric hospitals was illegal. He ordered that they should be integrated in February of 1969. I believe that that’s the last [inaudible 00:18:34] civil rights desegregation case in Alabama.

Kylie Smith:
A court case like this, the names are known. I was very lucky to find out a lot about one particular patient who had a very brave mother, who made a signed affidavit about the way that her son was treated at Searcy Hospital. She’s talked about how she went to visit him one day, and he was very upset. He took his mother and father into the bathroom and he showed them bruises and welts on his back where he had been dragged into a cupboard and beaten by two white male attendants.

Kylie Smith:
There could be a tendency to say, well, people who worked in psych hospitals, those attendants, they were not great anywhere. But she went on to say that she thought it was racially motivated. She pointed to the fact that both of those attendants who she named were members of the local clan, and that the clan had had a demonstration around Searcy Hospital at the time of the integration attempt.

Kylie Smith:
For me, that’s a really powerful story because it tells me that these hospitals are occurring in the middle of extreme violence, and they’re a part of this broader racial tension, and that they’re not immune to the effects of white supremacy. You think that these places that they’re called asylums, but there’s no asylum there. I think that that’s a really powerful, for me, a reminder of what people had to live with every day, and how much courage it took for her to put her name to an affidavit to the court to protect her son.

Brian Balogh:
You refer to the civil rights movement. I’d like you to address the ways in which mental health diagnoses were used to label and marginalize civil rights activists.

Kylie Smith:
That’s a really interesting question. When we talk about does the formal desegregation movement, does it end segregation in mental health hospitals? Yes, to some extent, because they throw thousands of patients out. They just throw them out on the street, they give them a prescription for Thorazine and say, see you later. Obviously, the numbers drop overall, but there are some other things happening in psychiatry and mental health that I think have continued that segregation and that are exactly as you said, specifically aimed at activism.

Kylie Smith:
In the mid-70s, the American Psychiatric Association changed its diagnostic criteria for schizophrenia. To one cluster of symptoms, it added the word aggressive, which had not been in that cluster of symptoms before. Then almost immediately pharmaceutical companies start advertising medication. There’s a famous ad for one particular medication called Haldol that was advertised to psychiatrists, and it shows a figure who looks like James Brown with a black power fist. It says, “Are your patients aggressive? Are they out of control?”

Brian Balogh:
Wow, this was advertised in magazines?

Kylie Smith:
Yeah, it was advertised in the Archives of General Psychiatry, a medical journal. We have come full circle back to this space where we’re… I don’t think this has ever gone away, this criminalization of black resistance, and not just criminalization, but that it’s pathological. I think that that’s also related to the underlying idea that black culture itself is pathological. We see that debate come up a lot in education, segregation, and the Moynihan Report about is black culture deprived? There’s already this idea that just to be black used to be mad in some way.

Brian Balogh:
Tell me more about where we are today. You certainly established a very long line of historical discrimination in the way diagnosis is used, and for that matter the way treatment is applied. What else explains that horrifying disparity that you talked about?

Kylie Smith:
We have a general problem with mental health infrastructure in the United States, generally. I think that is obvious to everyone. There are not enough services where people live, that there is a too easy overlay with incarceration. I think that those are very complicated historical problems, and they’re not always related purely to race. There’s an overlay with poverty, and there’s an overlay in the way that different states also will approach mental health infrastructure funding and insurance.

Kylie Smith:
It’s layers of complication. Mental Health funding and insurance depends on whether a particular state has expanded Medicare in a particular way. You’ll see states that haven’t expanded Medicare or Medicaid to cover mental illness. That’s where you’ll see an almost direct trans-institutionalization, where either people who are old go to nursing homes, and then people who are on public insurance with mental illness end up in prison. That’s why we now have a situation where prisons are the largest mental health providers in the country.

Brian Balogh:
Kylie Smith is an associate professor for nursing and the humanities at Emory University. She’s the author of the forthcoming book, Jim Crow in the Asylum” Psychiatry and civil rights in the American South. You also heard from Martin Summers, Professor of History and African Diaspora studies at Boston College. He’s the author of Madness in the City of Magnificent Intentions: A History of Race and Mental Illness in the Nation’s Capital.