States of Mind

This is a transcript from an earlier broadcast of this episode, there may be slight differences in wording.

BRIAN BALOGH: This is BackStory, I’m Brian Balogh. This month, the American Psychiatric Association released a new addition of its Diagnostic Bible, the DSM-5. It raises the question, how do we tell mental illness from mental health? for past generations of Americans, one part of the answer was political. During World War II, researchers with an eye on Nazi Germany came up with a nifty test to diagnose fascist thinking.

JAMIE COHEN-COLE: So if you agree strongly, this is an indication that you are fascist. Item number 41, the businessman and the manufacturer are more important to society than the artist and the professor.

BRIAN BALOGH: 20 years later, a different disorder was making headlines.

JONATHAN METZL: Leading psychiatric journals talk about the argument that black men who participated in civil rights protests were at risk of developing schizophrenia because protesting was driving them crazy.

BRIAN BALOGH: A history of mental illness, today on BackStory.

NARRATOR: Major funding for BackStory is provided by the National Endowment for the Humanities, the University of Virginia, the Joseph and Robert Cornell Memorial Foundation, and an anonymous donor.

ED AYERS: From the Virginia Foundation for the Humanities, this is BackStory, with the American Backstory hosts.

BRIAN BALOGH: Welcome to the show. I’m Brian Balogh, the 20th century guy, and I’m here with Peter Onuf.

PETER ONUF: 18th century guy.

BRIAN BALOGH: Sadly our 19th century guy, Ed, is away this week, which is too bad for him, because we’re going to talk, for a minute, about a person from his century, a Louisiana doctor named Samuel Cartwright.

DR. KATHERINE BANKOLE-MEDINA: He was greatly respected in the south. He was considered a rock star.

PETER ONUF: This is Katherine Bankole-Medina.

DR. KATHERINE BANKOLE-MEDINA: Professor of History at Coppin State University in Baltimore, Maryland.

PETER ONUF: And she’s been studying Dr. Cartwright for quite some time.

DR. KATHERINE BANKOLE-MEDINA: He actually served as an apprentice with Dr. Benjamin Rush of Philadelphia.

BRIAN BALOGH: He was a big deal.

DR. KATHERINE BANKOLE-MEDINA: Benjamin Rush was as big as you can get.

PETER ONUF: So in other words, the guy was no quack. In fact, he was one of the most influential American Medical figures in the years leading up to the Civil War, especially in the slave holding South.

BRIAN BALOGH: And one theory that he advanced was something called drapetomania. It sure isn’t a disease that doctors would diagnose today.

DR. KATHERINE BANKOLE-MEDINA: It was an illness described and defined as one that causes enslaved persons to run away from slavery, or to have thoughts of escape from bondage.

BRIAN BALOGH: OK. That was an illness?

DR. KATHERINE BANKOLE-MEDINA: Yes. Yes, he considered it an illness. He considered it a form of mental illness akin to madness.

BRIAN BALOGH: Wow. What was his treatment for this, I shudder to ask?

DR. KATHERINE BANKOLE-MEDINA: (LAUGHINGLY) Indeed, you should. He had some interesting treatments with respect to drapetomania. One of those is the idea that if the slaveholder would keep the enslaved person in an infantile state or in a submissive state, that kind of treatment would help to cure the person from wanting to be free. And if that failed, then the slave owner or the overseer could resort to whipping as a prevention against running away. And it was recommended as a cure.

BRIAN BALOGH: Cartwright’s theory didn’t only apply to African Americans in bondage. He thought the same diagnosis could apply to free black people, as well.

DR. KATHERINE BANKOLE-MEDINA: Cartwright had particular condemnation for free blacks. He believed that free blacks more often suffered from his negro slave disease than did the enslaved blacks.

BRIAN BALOGH: Sure, well, they weren’t being treated like children.

DR. KATHERINE BANKOLE-MEDINA: Absolutely. Absolutely. And Cartwright specifically spelled out that whenever you find free blacks in their own communities, in their own enclaves, actually behaving as if they were free, they were the ones who are suffering the most.

BRIAN BALOGH: A little over a week ago the American Psychiatric Association released a fifth revision of its Diagnostic and Statistical Manual, the DSM-5. Drapetomania isn’t in it. But some new disorders have sparked controversy.

According to some experts, this latest edition of the DSM will re-classify millions of previously normal people as having some sort of disorder. That’s going to have serious consequences for insurance coverage, patient care, and drug companies.

PETER ONUF: So today on BackStory, we’re going to look at the ways past generations of Americans have drawn the line between mental health and mental illness. Why have certain disorders disappeared a various points, only to be replaced by new ones?

We’ve got stories about a sleep walker at the foundation of the asylum movement, about how a few simple words changed activists into schizophrenics, and about a test that tells us if you yeah you, are susceptible to fascism.

NARRATOR: It’s often argued that a diagnosis can be limited by language. That the very words used to describe an illness can determine who is seen to have that illness. And this can have very real implications for those people diagnosed.

BRIAN BALOGH: In his book, The Protest Psychosis, Psychiatrist and Sociologist Jonathan Metzl looked at the new definition for schizophrenia that emerged in the 1968 version of the DSM. He discovered that it led to one particular demographic been disproportionately associated with the disease. Mental Story begins with a man that he calls Caesar Williams, committed to Michigan’s Ionia State Hospital for the Criminally Insane, in the 1950s.

JONATHAN METZL: He would have a pretty stable life, and then all of a sudden out of the blue would be involved in kind of travelling somewhere spontaneously, spending a lot of money, money that he didn’t have, and getting into particular fights.

And one day, lo and behold, at a time of great stress in his life– his wife was about to give birth to their child– he ended up traveling to Michigan and getting somehow involved in a card game that turned kind of violent, probably because he didn’t have the money, and ended up being arrested.

And when he was arrested, was saying that he was royalty, and the king, and other types of things. And so he was sent first to jail, and after a prolonged period of solitary confinement, where he was, I think, probably physically abused, was sent into a psychiatric hospital.

BRIAN BALOGH: And what was his diagnosis?

JONATHAN METZL: He was given a diagnosis, in the late 1950s, of what was called the psychopathic personality with psychosis. And what I found is that a lot of men like Mr. Williams, who were admitted in the 1950s and diagnosed with psychopathic personality disorder, or antisocial personality disorder, found that there are diagnosis changed while they were in the hospital. And particularly when the DSM II came out in 1968.

New terminology, particularly the terms were projection, projected anger, anger and hostility, these terms became part of the diagnosis of schizophrenia in 1968. And what we see is that the charts of people like Mr. Williams change, in which the doctors literally go through and change the diagnosis from a personality disorder to schizophrenia.

BRIAN BALOGH: Now as I recall, Mr. Williams was African American?

JONATHAN METZL: That’s right. That’s a very large factor in the way that his diagnosis played out. There’s particular language, language that’s actually coming from black power protests, that makes its way into psychiatric definitions of schizophrenia, in particular.

And so there are a bunch of articles that I look at that are from leading psychiatric journals, that talk about the argument– and this was not in any way made in secret, it was right there in the leading psychiatric journals of the time– that black men who participated in Civil Rights protests were at risk of developing schizophrenia, because protesting was driving them crazy.

And in fact, they coined a new term in a journal called the “Archives of General Psychiatry,” one of the leading psychiatric journals in the country, they coined this term called the protest psychosis, to talk about black men who were protesting against the government, or in Black Power protests, who are developing schizophrenia as a result of trying to assert their civil rights.

BRIAN BALOGH: Was there any discussion of paranoia? Because, as we know in retrospect, some civil rights activists had good reason to be, quote, “paranoid.” Their phones were being tapped.

JONATHAN METZL: It’s funny, because one of the cases that I look at is the case of Malcolm X. And Malcolm X had, at least according to the CIA file, it’s kind of contested, a family history of mental illness, they argued. And Malcolm X as much as anybody had reason to suspect that the government was about to get him, because he was being profiled, his phones were being tapped. And I’ve got the FBI profile, and they diagnosed Malcolm X with having schizophrenia, particularly because he was paranoid against the government.

And even though it’s incredibly tragic to read this file, you can’t but think like, of course he was paranoid against the government, because the government was profiling him and tapping his phone. So a lot of leaders at the time had psychological profiles that we’re done by the government. And they had good reason to be looking over their shoulder.

BRIAN BALOGH: So to return to the psychiatric implications of all of this, how does that influence Mr. Williams’ life?

JONATHAN METZL: At the time, there were tremendous diagnostics shifts that were happening, but also governments were deciding– because a lot of these asylums were federal funded– what types of diagnoses warranted long-term stay in psychiatric hospitals.

And certainly schizophrenia was identified as being a diagnosis that warranted more intense treatment and longer stays in an asylum. So by diagnosing a lot of these African American men, like Mr. Williams, with schizophrenia, they really did increase, not only the amount of time that these men were kept in asylums, but also limited their ability to contest their incarceration, or being kept there.

So I’ve got long letters and correspondences, for example, between family members and the doctors at Ionia where they were saying, he’s fine. Let him go. We’ll take care of him. And the response was, our job is to restore him to sanity. And because he had this schizophrenia diagnosis that implied that he was insane, it meant that he stayed in the asylum for quite a bit longer than they would have otherwise.

BRIAN BALOGH: What do you do, as a Professor of Psychiatry, to ensure that the social context that you live in does not to taint your treatment of patients?

JONATHAN METZL: That’s a wonderful question. I’ve actually had instances in my professional career where patients have come in to the clinics or emergency rooms where I’m working, and they voice exactly the themes that I write about in my book.

So when I was in Michigan, I was working in the ER one night, and there was an angry African American man who was brought in by the police with clearly having mental symptoms, delusions or hallucinations. And at that moment I’m not going to say, oh, we’re suffering from a socially constructed condition here that we need to look at culture.

I think that’s an answer that would be malpractice. But I will say that we have to remember the lessons of history, which is that our diagnoses, for better or worse, are shaped by social, and political, and environmental factors. And probably psychiatry more than other specialties.

And so the patient that I’m talking about was brought in, and even though he was clearly in distress, he was also talking about threats made against him by the police, an uncertainty. And I think that in a way, for me at least, knowing the particular context of the history, I would hope changed the kinds of questions that I asked of this patient.

I think all doctors, their main goal is to alleviate suffering. But I don’t think that we need to automatically discount the content of symptoms. And so in this case, I probably spent more time asking this person about his sense of safety and what the threat was.

BRIAN BALOGH: Jonathan Metzl is the Director at the Center for Medicine, Health, and Society at Vanderbilt University. It’s time for a short break. When we get back, a woman sleepwalks her way into fame, and a room at the brand new asylum.

PETER ONUF: You’re listening to Back Story. We’ll be back in a minute.

TONY FIELD: Hello, podcasters, Tony Field here, Senior Producer of the show. If you’ve been to backstoryradio.org lately, you may have noticed a few changes there. This past week, we went live with a brand new version of the site. It does everything the old one did, but, hopefully, a little better. Have a look and let us know what you think.

And while you’re there, take a moment to weigh in on our latest show in the works. It takes on the mighty Mississippi River, a battleground for so many of this country’s past struggles. We’ll have stories about steamboats, floods, and about the music that has flowed alongside the Mississippi waters. But we’d also love to hear from you.

Was reading Huck Finn a pivotal moment in your own young life? Have any good family stories about the Mississippi? Maybe you were affected by the floods there. Let us know. You can leave a note for us at the brand new backstoryradio.org, send an email to backstory@virginia.edu, or just give us a call. Our voice mail line is 434-260-1053. Now back to the show.

PETER ONUF: We’re Back with BackStory. I’m Peter Onuf.

BRIAN BALOGH: And I’m Brian Balogh. We’re talking today about the history of diagnosing mental illness in the United States.

PETER ONUF: The 1830s were a foundational time in treating the mentally ill. With the first state run asylums cropping up across the country, medical authorities had to decide who to put in them. At first, that meant the criminally insane. Prison inmates who are too dangerous to be around other, more stable prisoners.

But in an effort to keep the asylum from becoming a rug under which to sweep society’s worst, doctors began to look for other patients, more trainable patients to commit. Eric Mennel has the story of one of those patients.

ERIC MENNEL: On the night of June 24, 1833, Dr. Lemuel Belden received a message. There were concerns about the behavior of a young girl in Springfield, Massachusetts.

PORTRAYAL OF DR. LEMUEL BELDEN: I was called under the impression that she was deranged, and such at first was my own belief. She was struggling to get out of bed, complaining very much at the same time of pain in the left side of her head. Her face was flushed, the head hot, eyes closed, and her pulse much excited.

PROFESSOR BENJAMIN REISS: Jane C. Rider was a servant for a wealthy family. And she had had a fairly long history of sleep disturbances that went back into her childhood.

ERIC MENNEL: This is Benjamin Reiss, and he teaches at Emory University. And he stumbled on the Jane Rider story a few years back.

PROFESSOR BENJAMIN REISS: It was reported that she often slept too long, and that as a child she had a number of episodes of sleepwalking. And those started to get more intense as she came to work for this family.

PORTRAYAL OF DR. LEMUEL BELDEN: At first, the paroxysm

ERIC MENNEL: A paroxysm is a fit, or an attack.

PORTRAYAL OF DR. LEMUEL BELDEN: –occurred only in the night and generally soon after she went to bed. As the disease advanced, they commenced earlier. She then fell asleep in the evening sitting in her chair, or rather, passed into the state of somnambulism for her sleep, under those circumstances, was never natural.

PROFESSOR BENJAMIN REISS: So some of the things that she would do in the middle of the night would be setting the table, perfectly, for breakfast.

PORTRAYAL OF DR. LEMUEL BELDEN: Having dressed herself, she went downstairs and skimmed the milk, poured the cream into one cup and the milk into another, all without spilling a drop. She then cut the bread, placed it regularly on the plate, and divided the slices in the middle. And this with their eyes closed. She finally returned voluntarily to bed.

ERIC MENNEL: And when she’d wake up in the morning she wonder–

PROFESSOR BENJAMIN REISS: Why had somebody else done my job for me while I was sleeping?

ERIC MENNEL: Eventually, word of Jane’s behavior got around. Her sleep induced chores were written up in the local newspaper. And people wanted to see for themselves.

PROFESSOR BENJAMIN REISS: People would show up to watch this spectacle of her strange nighttime activities. And it’s not clear, exactly, how people knew when to show up, but there don’t seem to be any reports of people turning away dissatisfied. She was something of a medical curiosity.

ERIC MENNEL: It got to the point where Jane was not only doing work in her sleep, she was undoing work, work she was paid to do. Things like pulling clothes from her dresser and hiding them in places she couldn’t find when she woke.

PROFESSOR BENJAMIN REISS: And apparently after a while this became bothersome to the family that was employing her. They decided, and apparently Jane, herself, agreed–

PORTRAYAL OF DR. LEMUEL BELDEN: Arrangements were made for Jane’s removal to the hospital in Worcester–

PROFESSOR BENJAMIN REISS: The state lunatic asylum, which had only opened the year before.

PORTRAYAL OF DR. LEMUEL BELDEN: –where she could enjoy that’s a seclusion which seemed essential for her cure.

ERIC MENNEL: What’s important to note here is that just a few years prior Jane wouldn’t have been considered insane. In the 18th insanity was an entire way of being.

PROFESSOR BENJAMIN REISS: A complete delusional set of beliefs or, a kind of reversion to an almost animalistic state of behavior.

ERIC MENNEL: But by the time Jane Rider was making breakfast in bed–

PROFESSOR BENJAMIN REISS: –the concept of partial insanity took hold. And that is that you could be completely sane in most aspects of your life, but there would be one set of behaviors that could set you off, either religious delusion, or some kind of fixation, or troublesome behaviors in your sleep. So insanity started to become fractionalized, in a way.

ERIC MENNEL: A lot of this was caught up in ideas similar to phrenology, that different areas of your skull revealed different personality traits. The skull, the brain, and madness were all be broken down into their component parts in the 19th century. And with medical advances, scientists thought that if you could locate madness you could cure it. Essentially, everything must be curable, which is exactly how Jane C. Rider, a young, female servant who sleepwalked, was placed in the asylum system. A system mostly populated by the criminally insane.

PORTRAYAL OF DR. LEMUEL BELDEN: December 15, paroxysm rather singular. She is full of melancholy like a roguish child. December 19, she was more disposed to melancholy. She once said her head ached and felt strangely. She appeared very much like a person insane.

December 21, very well and wakeful all day, but in the evening had a paroxysm of complete insanity. Talked, ran about the house and refused to take her medicine. When forced to take it, she shed tears and fell into a sort of hysterical sobbing, which lasted some minutes.

ERIC MENNEL: Belden thought the problems were food related. Specifically, he blamed her restlessness on eating too much dried fruit. But even controlling Jane’s diet didn’t fix the problem. So doctors were forced to try more drastic cures.

PORTRAYAL OF DR. LEMUEL BELDEN: To warm the feet, which were always cold, the Nitro-Muriatic Acid bath was prescribed.

PROFESSOR BENJAMIN REISS: She was given everything from opium, to ether, to medications that would make her vomit.

PORTRAYAL OF DR. LEMUEL BELDEN: Her head was also shaved.

PROFESSOR BENJAMIN REISS: Leeches we’re applied. She was bled profusely. She had–

ERIC MENNEL: Leeches?

PROFESSOR BENJAMIN REISS: Leeches, yeah. She was blistered also. Pus would ooze out. There was some thought that it would draw out whatever fluids were not harmonized within her body they were causing her to behave in this way. So she went through this very painful and difficult set of treatments and experiments. And after a while, it was clear she wanted to get out of there.

PORTRAYAL OF JANE RIDER: Kind friend, as it was your wish that I should write to you respecting my health, I have a good opportunity now.

ERIC MENNEL: This is from a letter Rider wrote to Belden just before being dismissed from the asylum. And reading the letter, the words don’t seem like those of a woman who has effectively been a lab rat for the past few months. They seem more like a woman who wants to leave and will say whatever she needs do to make that happen.

PORTRAYAL OF JANE RIDER: I am very happy to say, I’m much better now. And think that being a little more unwell than usual has had a very good effect. The time has passed very quickly.

ERIC MENNEL: Do the doctors, in the end, feel like they have cured her?

PROFESSOR BENJAMIN REISS: In the final write up of the case they said that her symptoms had become much more manageable, which was, in a way, an admission that they couldn’t completely cure the problem. Now asylum superintendents at that time, they always had an out. Because they claimed that mental illness was universally curable if it was caught early in its development.

And so they often took pains, when they couldn’t cure somebody, to show that this was a disease that had been growing for years and years before it was ever brought to their attention. And the fact that Jane Rider had been experiencing bouts of sleepwalking since she was a young girl helped give them cover.

ERIC MENNEL: One thing, though, that was interesting about the story is where I can’t tell if by putting her in an asylum it’s a humanitarian effort that they want to treat her? That seems like that’s what Belden, the doctor, it seems like that’s his motivation. But simultaneously, it seems like the family, her employers are trying to just going to get her out of their hair. I mean, do you get a sense that both those things are working in confluence with each other? Or one is more powerful than the other?

PROFESSOR BENJAMIN REISS: I think both are working together, and they’re often indistinguishable from each other. The reigning idea behind the asylum movement was that all people had access to mental health, and to productive lives. And that when medical conditions prevented them from fulfilling their potential, that society had had an obligation to restore them to full capacity.

That was the PR, and often the reality was quite different, when people who were simply inconvenient to others, as Jane Rider seemed to become to her employers, found themselves incarcerated either through coercion, or through outright involuntary confinement. That tension between the humanitarian mission and the control of unruly individuals was always present through the history of the asylum.

ERIC MENNEL: And we don’t know what happened to her after she left the asylum?

PROFESSOR BENJAMIN REISS: Well, we know she went back to working as a servant. And periodically, newspaper and magazine reporters would inquire into the case and give brief accounts of how she was doing. But she slips back into the obscurity of the world of 19th century serving women.

BRIAN BALOGH: ERIC MENNEL: It’s strange to think that mental illness might have been a way out of that obscurity, even if temporarily. And it’s difficult to know what a Rider was actually thinking. After all, she wrote these letters knowing full well they would be read by the doctors treating her. Whatever the case, it was these letters and others like them that helped to give authority to the asylum movement, that helped launch a century and a half of institutionalization.

PORTRAYAL OF JANE RIDER: I feel as if I never could repay my friends for all they have done for me. Indeed I know I never can. All I can do is thank them, and deny myself everything that would be injurious to my health. I have nothing more at present to write. Your must obedient friend, Jane C. Rider.

PETER ONUF: Eric Mennel is one of our producers. Special thanks to Benjamin Reiss for helping tell the story of Jane Rider. His book about culture in 19th century asylums as called Theaters of Madness.

BRIAN BALOGH: Hey, Peter, I never thought that a story about leeches would turn into a feel good ending.

PETER ONUF: Well it’s an age of reform. This is the era of Women’s Rights, of temperance, of anti-slavery, you name it. We can make things better. And I think that you can listen to the story and you hear optimism. You hear the possibility that yes, these new institutions, maybe they are the solution. Maybe we can at least begin. Because, the idea of progress is not that you know everything now, but that one day you will.

BRIAN BALOGH: Yeah, speaking of progress, it goes down the tubes as far as the asylum is concerned, because by the end of the 19th century, these are large institutions. Two or three times the size. They’re warehousing people who are chronically ill. And while the institution was able to serve Jane Rider, it turns out that for every Jane Rider there were three or four more people who needed this kind of care and couldn’t get it.

PETER ONUF: Brian, I think this is a classic story that asylum keepers were too successful in the way they sold themselves to the larger public that they could do something, while they couldn’t really do much. But they always could get people into these asylums and out of society, out of families. Troublesome people could be warehoused. So the success in claiming to be able to deal with people with these mental problems led to this paradoxical situation where they couldn’t really deliver care because of the sheer numbers of people involved.

BRIAN BALOGH: Yeah, and the irony, Peter, is they did cure a lot of people, or a lot of people did you get better. Those people left the institution. So over time, you first had increasingly populations that were chronically ill. And then by the end of the 19th century, for very complicated reasons having to do with funding, you got more and more elderly people who pretty much went there to die.

You know, Peter, for better or worse, the story of the asylum in America it doesn’t end there. In the 20th century it morphs yet again. We called up Alan Horwitz a sociologist who has written a lot about the history of psychiatry, and he explained what happened next.

ALAN HORWITZ: For most of the 20th century, mental hospitals were at the core of the psychiatric profession. And most psychiatrists practiced in inpatient mental institutions. Really it was psychoanalysis that made the major change, where they pretty much thought mental problems we’re just extensions of ordinary kinds of psychosocial problems.

PETER ONUF: In addition to the psychotic, who had long been institutionalized, psychiatrists began to focus on the neurotic. People who weren’t in danger of being committed, but who needed help, nonetheless.

ALAN HORWITZ: So that instead of the sharp dichotomy between people who are basically considered crazy and those who are sane, what you get is a much more gradual transition between sanity and normality.

PETER ONUF: These gradations were laid out in a document the American Psychiatric Association released in 1952. They called it the “Diagnostic and Statistical Manual” or DSM.

BRIAN BALOGH: A second edition was published in 1968. Like the first one, it was intended as a compendium of the range of mental disorders and their probable causes.

ALAN HORWITZ: So for example, this is the entire definition of depression in the DSM II. And it’s, quote, “This disorder is manifested by an excessive reaction of depression due to an internal conflict or to an identifiable event, such as the loss of a love object or cherished possession.” That’s it.

BRIAN BALOGH: Wow! They violated my elementary school teacher’s rule. Never define something with the thing you’re defining.

ALAN HORWITZ: Right. Exactly. When it says that manifested by an excessive reaction of depression, yes, it’s quite circular.

BRIAN BALOGH: Psychoanalysts were OK with these broad definitions. After all, they were mainly interested in the distinctive details of the patient’s unconscious lives. But, says Alan Horwitz, there was a problem.

ALAN HORWITZ: The major problem was that it’s not a very medical way of thinking about things. That it didn’t give you sharp diseases.

BRIAN BALOGH: It was in this context that psychiatrists went back to the drawing board. And in 1980, they released a third version of their manual, the DSM III. Alan Horowitz says, it was nothing short of a paradigm shift.

ALAN HORWITZ: DSM III really medicalized psychiatry. The criteria, say, for depression, you have five symptoms. If you have fewer than five, you don’t have the condition. So you have the kinds of discrete categories that you have in other medical disciplines, that you didn’t have before the DSM III.

BRIAN BALOGH: The new paradigm was a real win for research psychiatrists who had pushing for years for a more uniform way of talking about mental illness. And for pharmaceutical companies, who could now use that checklist to pitch specific symptoms to doctors and patients that they should look out for.

PETER ONUF: Psychoanalysts, on the other hand, weren’t so happy. Because the new focus on symptoms left no room for considerations of root causes.

ALAN HORWITZ: With the single exception of bereavement, there’s no context in it, at all.

BRIAN BALOGH: What we’re left with, says Horowitz, is a system that does not distinguish between real depression and the kind of temporary sadness that is the natural human response to a range of life events. Both are now lumped together into one diagnosis, which in turn, frequently results in a prescription for drugs.

ALAN HORWITZ: I think that psychiatric researchers are finding that the paradigm they’ve been using since the DSM III just hasn’t worked very well. That it hasn’t produced the kinds of breakthroughs, regarding the treatments for conditions, that they expected it would have. And I think there’s a growing recognition that it’s the current DSM system itself that is almost holding back progress. And many of the proposals that you see for changing it, really do hearken back to systems that were more common before the DSM III in 1980.

BRIAN BALOGH: In other words, getting back to root causes. But these days, those causes are more likely to be seen in the chemistry of the brain than in uncovering the deep history of a person’s mental suffering. It’s time for another short break, but stick around. When we get back, a psychological test that promised to identify people who threatened American democracy.

PETER ONUF: More BackStory coming up in a minute.

We’re back with BackStory. I’m Peter Onuf.

BRIAN BALOGH: And I’m Brian Balogh. Today, we’re taking on the history of mental illness in America.

PETER ONUF: In 1950, four researchers at the University of California Berkeley published a 999 page study that would dramatically shape psychology for the next couple of decades. It was called the “Authoritarian Personality,” and it attempted to figure out why some people embraced authoritarianism while others didn’t.

BRIAN BALOGH: This research had begun in the midst of World War II. And two of the researchers, Theodor Adorno and Else Frenkel-Brunswick had, themselves, fled Nazi Germany in the 1930s. So they had a very personal interest in this study. The big question was, might Americans ever embrace fascism on a large scale? Could anybody embrace authoritarian beliefs?

PETER ONUF: The answer they arrived at was essentially this, what made some likely to embrace authoritarian politics was a specific type of disordered personality, close-minded conformists deferential to power. People with this so-called authoritarian personality, the researchers thought, posed a threat to America’s democratic society.

And so they put together a bunch of tests that could help identify these dangerous authoritarian types. There was the AS-scale, which tested for antisemitism, There was E-scale for ethnocentrism. And then there was the F-scale.

JAMIE COHEN-COLE: For fascists, yeah.

BRIAN BALOGH: This is Jamie Cohen-Cole, an Assistant Professor of American Studies at George Washington University.

JAMIE COHEN-COLE: So if you agree strongly, this is an indication that you are fascist. OK. So this is item number 31. Nowadays, more and more people are prying into matters that should remain personal and private.

BRIAN BALOGH: I’m ambivalent on that.

JAMIE COHEN-COLE: You’re ambivalent on that. OK. So you don’t point in either direction on that one, then.

BRIAN BALOGH: No. Hit me with another one.

JAMIE COHEN-COLE: People can be divided into two distinct classes, the weak and the strong.

BRIAN BALOGH: So everything is very clear cut, if you’re going to score high on this personality.

JAMIE COHEN-COLE: Yes. Item number 41, the businessman and the manufacturer are more important to society than the artist and the professor.

BRIAN BALOGH: This has to do with psychology, not politics?

JAMIE COHEN-COLE: OK. So the argument is, is that people who score high on this test, that is, who agree a lot with these terms, that they would score high on all of these things. So they’re conventional. They have tendencies toward authoritarian submission. They have authoritarian aggression. They have anti-interception.

BRIAN BALOGH: I’m sorry. Anti-interception?

JAMIE COHEN-COLE: So they are opposed to the subjective, the imaginative, or the tender-minded.

BRIAN BALOGH: So by covering these different realms, they really get at the essence of the individual, not just political views? Or so they would argue.

JAMIE COHEN-COLE: Right. The larger conclusion was to argue that there was such a thing as an authoritarian personality. That authoritarianism was composed of these different subcategories that belong together. That fascistic kinds of thinking explain not only racism, but also antisemitism. And also explains certain beliefs about child rearing, certain beliefs about religion, certain beliefs about conformist behavior.

BRIAN BALOGH: How was this received? Did this make a big splash? Did this make much of an impact in America in the early 1950s?

JAMIE COHEN-COLE: So, yes, it had an enormous impact. The member’s of the group they wrote this book were mostly left leaning. They were generally opposed to McCarthyism and actually wanted to describe right-wing politics as being best explained by the categories of the authoritarian personality.

And then what happened is, that because it was picked up by so many social psychologists, but also by widely read sociologists and historians– so here, it would be worth noting the work of Daniel Bell and his collaborators in a book known as The Radical Right. Collaborators included historian Richard Hofstadter.

For these social thinkers who were trying to explain, how do we understand the way which segments American society supported clearly anti-American positions, anti-democratic positions that Joe McCarthy was taking, the abridgment of the Constitution, and the Rights to Freedom Association? And the way to make sense of this was to understand those members of the American population who had subscribed to McCarthyism.

To understand them as having a certain form of mental illness, in which they would be attached to a strong leader. In which they would assign all of the problems that they saw in national life and in culture to an out group, that is, people not like them. So to communists, to minority groups. And that would then be the explanation of that particular problem.

BRIAN BALOGH: Well, if I were researcher, where would I look across the spectrum of American society to find these authoritarian McCarthyite types?

JAMIE COHEN-COLE: For the psychologist reading this book, and the sociologists, the most obvious example of these people would be small shopkeepers, housewives, the kind of lower middle class. They’re basically thinking about the prototype example of people who were the first joiners of the Nazi party.

BRIAN BALOGH: Yet, the authoritarian personality, if I’m not mistaken, ends up getting applied to people on the left eventually. How does that happen?

JAMIE COHEN-COLE: So because this book was so important in the field of social psychology and sociology, it received a lot of attention for its methodological claims and the way that is understood individuals. And two modes of criticism made what you talked about happen, that is, is the application of [INAUDIBLE] personality people on the left.

On the one hand, Edward Shils, who was a right-leaning sociologist, argued that all of the problems with the authoritarian personality, which if you read the book seems to be mostly people on the right, could best be applied, perhaps, to Marxists, and to Communists.

And so he wrote a lengthy critique of the “Authoritarian Personality” making sure that we would think about how Marxists had all of the conformist irrationality that had been assigned to McCarthyites and to fascists. So that’s part one.

The other part is, that social psychology has been struggling since its birth to claim that it is a hard science, that it is as good a science and as rigorous a science as the natural sciences. And one way to do that is to make sure that there’s no politics involved.

And so a psychologist by the name and Milton Rokeach adopted a new term, closed-minded, rather than authoritarian as a way of talking about people whose political views were outside of the most common centrist views. And its with that invention that the field above political psychology could claim that it wasn’t only looking at people at the right, but simply looking at people who had unconventional political views.

BRIAN BALOGH: So if the central concern of the authors of the “Authoritarian Personality” was avoiding conformity, avoiding rigid thinking, didn’t they contribute to creating that kind of society by marginalizing so many different perspectives?

JAMIE COHEN-COLE: Right. Indeed so. And that’s one of the ironies of this work. And, I mean, an even, maybe, deeper irony is that one of the ways that they said you can recognize an authoritarian personality is that they applied a categorical way, a bipolar way of understanding the world. That is, there’s the inside group and the outside group. There’s Aryans and non-Aryans, for instance. And then they then proceeded to apply a bipolar way of thinking about American society.

We have the authoritarian and democratic minded. And it took really until the mid ’60s when, mostly people on the left started to criticize the framing of the authoritarian personality and closed-mindedness as producing conformity in and of itself.

BRIAN BALOGH: That was Jamie Cohen-Cole, an Assistant Professor of American Studies at George Washington University. His forthcoming book is, The Open Mind; Cold War Politics and the Sciences of Human Nature.

PETER ONUF: If you’d like to rank your own level of fascistic thinking, you can take a version of the F-scale on our website, backstoryradio.org.

BRIAN BALOGH: At the beginning of the show, we heard a little bit about schizophrenia’s history as a diagnosis. To end our show today, we’re going to hear from a person who has firsthand experience with that diagnosis. Her name is Elyn Saks, and she’s a Law Professor at the University of Southern California. In 2007, Saks published an autobiography that chronicled her own struggles with the disease. Peter and I reached her at her office.

ELYN SAKS: So basically, schizophrenia, the analogy I give is to a waking nightmare, with all the bizarre images, impossible things happening, and the utter, utter fear. Only with a nightmare, you sit up in bed, open your eyes, and it goes away. No such luck with a psychotic episode.

So for me, my schizophrenia involves delusions. Fixes and false beliefs without evidence. Like, that I’ve killed hundreds of thousands of people with my thoughts. Hallucinations, like, I remember once I saw a man standing with a raised knife. Disorganized and incoherent thinking and speech.

So I had a breakdown on the roof at the Yale Law School my first year there. And I told my friends, I said, are you having the same experience as I am, of words jumping around the cases? I think someone’s infiltrated my cases. We’ve got a case at joint. I don’t believe in joints. But they to do hold your body together. So words are loosely associated but put together don’t make any sense.

BRIAN BALOGH: Professor Saks, did you have experience in an institution? Were you confined to an institution?

ELYN SAKS: I was. I was hospitalized in England, Oxford, England, in around ’77, ’78 for a month. And then the following year for four months. And then my first year at Yale Law School for five months. And that was ’82, ’83. I haven’t been hospitalized since then, although it’s been suggested on occasion. And in a way, my proudest accomplishment, that I’ve been able to function without being hospitalized again.

PETER ONUF: And how did you accomplish that?

ELYN SAKS: Well, I mean, I’d like to say something, first, about my doctors, which since I’ve been hospitalized all those many years ago I’ve had serious episodes, and might have seemed scary and worrisome. And I really cherish and honor the fact that my doctors were willing to sit with a certain amount of anxiety about my dangerousness to myself and other people, for the sake of respecting my wishes not to be hospitalized. It would have been much easier for them just to kind of the book at me, so to speak.

With my friends and family, you know, I don’t really show my illness, except to like my closest friends and my husband, occasionally. And they’re wonderful. They’re supportive. They’re kind. They usually to say to me– and this works for me, but not other people– Elyn, it looks like you’re having a really hard time. It’s probably your illness acting up. Let’s call your doctor, and maybe you need to get on more medication.

So for me, that kind of supportive response is extremely helpful. I have a bipolar friend I tried that with, and he got furious. How dare you say that? So it’s not one size fits all. But I’ve had excellent treatment. Five day a week psychoanalytic therapy for decades and continuing. Excellence psycopharmacology. Once I accepted the need for it. And then a really wonderfully accommodating workplace. It’s a very intellectually stimulating place.

And for me, using my mind to work on a puzzle, or write an argument, or a counterargument is one of my best defenses against my mental illness.

NARRATOR: Professor Saks, since we are with one real historian, at least, Peter Onuf, I’ve got to ask him, how would somebody who presented with these kinds of symptoms, how would they’ve been treated, Peter, in the 18th century?

PETER ONUF: Well, one solution is sequestration, to use a current term. That’s the legendary mad woman in the attic. Being kept restraint, I mean, restraint is probably the common theme, restraint and isolation, given the fact that nobody understood what was happening. Or they attributed it to demons, or possession of some sort, or later on more humanely, to environmental circumstances.

There weren’t any obvious and easy ways to deal with this. It’s not as if people in olden times, just because they couldn’t diagnose things, that they could deal– they could not deal humanely with these situations.

BRIAN BALOGH: Professor Saks, were you constrained when you were in institutions?

ELYN SAKS: I was restrained. You know, for the first couple of days, 20 hours a day. And then for three weeks, maybe five to 15 hours a day for three weeks. It was incredibly traumatic. I had nightmares about it for years. Just, you know, you feel helpless. You feel confused. You never know what you can do to get out. You don’t know how long you’ll be in.

Actually being restraints for over, say, 10 hours, your limbs really start aching. So it’s very painful, as well. And also, there’s evidence that it can be harmful. So the Hartford Courant did a series about restraint deaths. And at they had a Harvard statistician make some estimates, based on the data. And he estimated that every week, one to three people die in restraints. They aspirate or vomit. They have a heart attack. They strangle.

BRIAN BALOGH: So I gather that restraints are still being used?

ELYN SAKS: They are. There’s kind of a trend to stop using them, but there are places that still use them quite a bit.

BRIAN BALOGH: So you you’ve been very gracious about the psychiatric profession. And in fact, you claim that they’ve helped you tremendously, yet they continue to use these restraints. What do you make of that?

ELYN SAKS: Well, I mean, what I’d like to say about treatment is that I’m very pro psychiatry, but I’m very anti force.

BRIAN BALOGH: I see.

ELYN SAKS: I think force is a terrible thing to do to another human being with a terrible illness. It’s not a stable solution. Once you start administering the force the person who has no incentive not to go back. And what I think we should do is study ways to get people to want treatment, so we don’t have to use force.

BRIAN BALOGH: I want to take you, strangely enough, back to Peter’s century. Because, you talked about friends and, I know in some of the material I’ve read about you, you have a very loving husband. Clearly, medication has helped. Clearly, psychoanalysis has helped. But back in Peter’s day, they had friends, and they had family. Am I wrong about that, Peter? You had friends and family back in your period, right?

PETER ONUF: Yeah, we certainly did. Let’s not romanticize them, though. This is the pre-romantic period. But you’re constantly under surveillance. And it may be the modern invention of surveillance and restraint is a substitute for the thick social relations of the early modern period.

ELYN SAKS: Interesting. Well, they actually say that people with schizophrenia do a lot better in developing countries than they do in industrialized societies. And it may be because families are closer, and there’s more tolerance of difference, and that kind of thing.

BRIAN BALOGH: I’d be curious to know what it felt like when you did reveal to the world that you’re a schizophrenic?

ELYN SAKS: You know, it’s sort of interesting, because one of my friends said that I should do my book under a pseudonym. Did I want to become known as quote, “the schizophrenic with a job?” And I didn’t want to become known that way. But then I thought I couldn’t do anything that could be more helpful to people, potentially, than by actually telling my story. Because, it’s a story, thank God, that has a happy ending. And that may give other people hope and understanding. And that feels good to me.

I’m part of Glenn Close’s board, that has members that study stigma. And they find that people coming to understand the mental illness is a brain disease doesn’t reduce stigma, but people putting a human face on the disorder does. And especially if it’s like your workplace. You know the person in the office next door has a mental illness, but you see that they, pretty much, are just like you, and they want the things you want. And they have the same fears and anxieties.

And so I think coming forward is a good thing. It’s easy for me to say, as a woman with tenure. But other people are pretty established, and could do it. And I think if they can, it’s a good thing to do.

PETER ONUF: Well, you’ve done an amazing thing. Which is to take responsibility for your life, and the way you’re treated, knowing that you’re not fully responsible and you need help. It seems to me there’s a big tension, and it’s very hard for us, in our culture, to resolve that.

Between notions of personal responsibility, which go back to the very idea of consent, a regime that’s based on consent. And on the other hand, taking care of others. That sense of social responsibility.

ELYN SAKS: Right. Yeah, that’s extremely well put. I think that’s exactly right.

BRIAN BALOGH: Well, I want to thank you for joining us today, Professor Saks. This has been so illuminating.

ELYN SAKS: Well, thank you.

BRIAN BALOGH: That’s going to do it for today’s show. As always, we’ve posted a whole trove of related web resources about today’s topic at backstoryradio.org.

PETER ONUF: We’ll be back next week with Ed Ayers in tow. In the meantime, please, don’t be a stranger.

BRIAN BALOGH: Today’s episode BackStory was produced by Chioke I’anson, Jess Engebretson, Eric Mennel, and Tony Field, with help from Emily Charnock. Jamal Millner is our engineer. Special thanks today, Justin Hapley, Paul Learner, Alvin Poussaint, Laina Richards, and Robert Spitzer. BackStory’s Executive Producer is Andrew Wyndham.

Major support for BackStory is provided by the National Endowment for the Humanities, the Joseph and Robert Cornell Memorial Foundation, the University of Virginia, Weinstein Properties, an anonymous donor, and The History Channel, history made every day.

JESS ENGEBRETSON: Peter Onuf and Brian Balogh are Professors at the University of Virginia’s Corcoran Department of History. Ed Ayers is President and Professor of History at the University of Richmond. BackStory was created by Andrew Wyndham for the Virginia Foundation for the Humanities.