Race and racism have played a particularly significant role in the development of modern medicine, from the notorious Tuskegee syphilis experiments to the creation of the first immortal human cell line HeLa. In many ways, the influence of racism on American medicine has shaped approaches to bioethics and healthcare, continuing to inform the challenges patients and providers face today.

In Administrations of Lunacy: Racism and the Haunting of American Psychiatry at the Milledgeville Asylum, published in April 2020 by The New Press, Mab Segrest, PhD, uncovers the harrowing story of the Georgia State Lunatic, Idiot, and Epileptic Asylum. Dr Segrest, Fuller-Maathai Professor Emeritus of Gender and Womens Studies at Connecticut College, New London, traces the history of this institution through the Civil War to the post-Jim Crow era, centering the narrative around the voices of its former patients.

For mental health professionals, Administrations of Lunacy offers a critical exploration of psychiatrys historic links to key moments in American history by focusing on an asylum that was the largest in the world in the mid-20th century. To learn more about this history, we spoke with the author about her book. The following interview has been edited for clarity and length.

What can mental health providers learn from the history outlined in your book?

Mental health providers can learn from Administrations of Lunacy the importance of history itselfthe overarching sweep of itthat informs the particular (micro) histories that patients or clients bring in the door to their practices. They can learn the dangers of applying a strictly biomedical model stripped of the sources of historical and local traumas.

My deep history of this Georgia hospital, at times the largest in the world and by the mid-20th century one of the worst, is intended to shape the way that historians and healthcare professionals think about psychiatric history in its relationship to larger historical trends. My book shows how the extraction of history from an understanding of symptoms happened in a state asylum. It also details what that extraction allowed in terms of what came to be eugenics, which was a weaponizing of the symptoms of suffering against the very people most vulnerable to histories of conquest and exploitation.

Finally, given that 90% of public psychiatric beds today are in jails and prisons, psychiatry as a profession has a responsibility for those patients beyond providing them medications. I would like to see major psychiatric professional organizations take a stand against mass incarceration on the basis of its mental and physical cruelties that eviscerate real treatment.

There has been a degree of nostalgia for the asylum era recently. Why do you think this nostalgia has arisen now, and in your opinion, what, if anything, did asylums have to offer?

First, its important to clarify: nostalgia for whom? None of the expatients of those public institutions have shown much of this nostalgia. Early in my research, I twice visited the Central State Hospital campus with Georgia Consumer Council membersusers and survivors of Georgias hospital system. Larry Fricks, who was the state liaison facilitating the meeting, explained to me that for many of these consumers coming back to the hospital was the equivalent of coming back to Auschwitz. No nostalgia there.

By the turn of the 20th century the idea of the hospital as asylum or a safe refuge had failed, largely from overcrowding. The original Enlightenment philosophy of moral therapy believed that providing the mad structure, listening doctors, natural beauty, nutrition, and a respite from family could be curative. But moral therapy was intended for an institution of 300 patients. The level of overcrowding made them custodial, if not carceral institutions. By the 1910s in Georgia, there was brutality by orderlies, use of seclusion, and pressures for patients to work. After World War II, journalists exposes revealed these hospitals with electroshock administered by orderlies, understaffing, and overcrowded wards as the shame of the states.2

Today, what accounts for the crises in the mental health system is not the absence of this asylum. The transit between psych wards, jails, homeless shelters, and the streets came from the failure to provide support for the community care that should have accompanied deinstitutionalization as envisioned by JFK. Instead of the 1500 clinics projected for local communities, the US got mass incarceration, or a growth in the prison population from 300,000 to 2.3 million from the 1980s to 2010, what Michelle Alexander called a New Jim Crow.3

Anyone today who advocates for the asylums return is advocating for the most retrograde of psychiatric policies and the most terrible examples of psychiatric treatment from United States history. The call for a return to the asylum signals for me a continued refusal to use sufficient public monies to meet public needs, including mental and physical health. Whether we need more places where people in crisis can get longer term care regardless of social class or race is another question entirely.

What is transinstitutionalization and how does it differ from deinstitutionalization?

These are terms from social geographers that help map out the historic periods of psychiatric institutions. The first phase is institutionalization: the use of the spaces where lunatics were confined as a healing place rather than as custodial or punitive. This was a program of the Enlightenment and its goal was called the moral therapy. Deinstitutionalization is what happened in the United States after 1960, when about half a million patients in state hospitals were gradually released from these abysmally failed institutions. Transinstitutionalization is what happened when there was insufficient community care back home, which coincided with mass incarceration.

What role did southern asylum psychiatry play on a national level?

Southern asylum psychiatry illustrates the paradoxical process by which the worst becomes the norm. Most psychiatric histories from the 18th or 19th centuries mainly see southern asylums as scientifically retrograde. But in the antebellum period, the science in these mostly northeastern institutions was not always up to snuff by todays standards. Generally, asylum superintendents across the United States held the same racist ideas as southern superintendents did about African Americans and Indigenous people as primitives and savages. The profession as a whole in The American Journal of Insanity avoided discussion of slavery and abolition as too exciting, preferring to speak about such issues through allusions.1

Asylum superintendents were the first psychiatrists, although they were not termed so then. After the restoration of southern white supremacy, professionals across the nation granted white southern asylum superintendents the authority of expertise on African Americans, given that 90% of African Americans lived in the South before 1900. Southern asylum superintendents officially confirmed that emancipation was prejudicial to the negro in 1895, a shocking assertion! This attitude carries over today. The legacy of this attitude is the false belief that negative health results for marginalized people do not come from structural racism and sexism, but the inherent nature of those people.

The fact that Georgias state hospital explains so much about national failures today illuminates the pull towards the bottom that this white supremacist model exerts on national policies. In the 1950s, the Georgia state hospital was the largest in the county, the state, and the nation. Today, the Baldwin County Jail is the largest mental institution in the county, with the Fulton County Jails being the largest in Georgia and the Cook County Jail the largest in the United States. How do we comprehend this shift?

At one point, the asylum spent 5 times more on farming compared to patients. What role did patient exploitation play in Milledgeville and how did the asylum resemble a plantation?

Patient exploitation at the Georgia Asylum took the form of occupational therapy that filled the gap from the absence of other resources or treatments for patients. A careful examination of Georgia Asylum annual reports in the last 2 decades of the 19th century showed how moral therapy gave way to occupational therapy, which involved a huge farming operation producing tons of vegetables, plus cows, chickens, and pigs. As far as I can tell, the patients were not getting much of this food.

Race and gender shaped work regimessewing for white women, laundry for Black women, gardening for white men, growing cotton and other cash crops for Black men. These work regimes were not as bad as those in the convict lease system, which consumed many more African American men than the asylum. This is not to say that patients did not leave the institution, some of them improved, but many died there.

This plantation and labor influence showed up in a 1950 annual report that described the hospitals abattoir. The possibility that mentally ill patients could be staffing any part of a slaughterhouse is perhaps the most nightmarish scenario in the whole book.

What are the dangers of therapeutic pessimism? How did they inform Kraepelinian psychiatry, and does this notion create problems for psychiatry now?

In the 19th century, therapeutic pessimism came from the realization that medicine had found no cure for the problems that showed up in asylums. Within this mindset, the curative environment became custodial in increasingly overcrowded state institutions.

The diagnostic system of Emil Kraepelin, developed in Germany, replaced the hope of treatment with the process of classifications based on the trajectory of the disease. In this diagnostic system, the principal mental illnesses were manic depression and dementia praecox, or schizophrenia. Georgia case histories from 1909 to 1924 recorded verbatim interviews with patients as ill equipped doctors struggled to apply these categories to mostly poor Georgians.

For decades, Freudian psychoanalysis replaced Kraepelins diagnostics. Diagnostic and Statistical Manual of Mental Disorders (DSM)-III heralded a return to biological psychiatry at a time when new technologies of brain imaging raised expectations of new miracle drugs. But by the time DSM-5 was published in 2013, there emerged a lack of biomarkers to substantiate DSM-5 categories. In 2013, the National Institutes of Mental Health (NIHM) Director Tom Insel, MD, explained that the NIMH would be reorienting research away from DSM categories.4 This collapse of the DSM could create a vacuum into which pessimistic therapies reemerge.

Alternatively, DSM-5 also led humanistic professionals to call for a descriptive and empirical approachunencumbered by previous deductive and theoretical models. These professionals eschewed its overdiagnoses, false epidemics, stigmatizing of vulnerable populations, and biomedical models absent any awareness of sociocultural variations.5 I found these issues of DSM-5 characteristic of state asylum psychiatry as a whole, and Administrations of Lunacy aligns itself with this call for rethinking.

How did the eugenics movement and race science relate to psychiatry?

Eugenics, or the science of better breeding, arose in Europe in the 19th century and arrived in the United States in the early 20th century. It was supported by some of the biggest family fortunes of the Robber Barron era, and its offices at Cold Spring Harbor provided a base from which eugenic ideas spread rapidly. Eugenic sterilization had long been a goal of US eugenicists, and the US Supreme Court decision Buck v Bell in 1928 opened the floodgates. In the 1930s, state sponsored eugenics came to Georgia, although the institution had been performing this operation of a certain class at the turn of the century.

The state hospitals and newer institutions for the feebleminded had by the 1930s gathered people whom eugenics had branded as unfit, and they were prime targets of sterilization. In Georgia, sterilization was most rampant under Superintendent Peacock in the 1950s, a man who served (surreally) as both Superintendent and Chair of the Georgia Eugenics Commission. Peacock would write letters to and from himself asking for and granting sterilizations for particular patients.

Milledgeville was the site of several major epidemics, including syphilis, pellagra, and tuberculosis (TB). How did these diseases affect the asylum, and how might the current COVID-19 pandemic affect psychiatric patients?

These epidemics of syphilis, pellagra, TB, or hookworms were not primarily psychiatric in nature. But TB, syphilis, and pellagra had neurological effects that landed people in state hospitals. Treatment of those underlying effects, for example nutritionally with niacin for pellagra or antibiotics for TB and syphilis, eventually took care of neurological symptoms.

I have not heard how COVID-19 might register in terms of psychiatric symptoms, but certainly the pandemic and our highly inadequate responses to it creates its own negative environments for us. In general, a strong public health system that puts out accurate information to the general public and a federal government willing to take the lead to coordinate our responses according to the latest information would be profoundly reassuring and stabilizing. Unfortunately, that is not what we have.

References

1. Segrest, Mab. Administrations of Lunacy: Racism and the Haunting of American Psychiatry at the Milledgeville Asylum. The New Press; 2020.

2. Deutsch, Albert. The Shame of the States. Harcourt, Brace; 1948.

3. Alexander, Michelle. The New Jim Crow: Mass Incarceration in the Age of Colorblindness. New Press; 2010.

4. Insel, Thomas. Transforming Diagnosis. NIMH Directors Blog Posts from 2013. National Institute of Mental Health. Published online April 29, 2013. http://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml

5. Kamens SR, Elkins DN, Robbins BD. Open Letter to the DSM-5. Journal of Humanistic Psychology. 2013;1-13. doi:10.1177/0022167817699261

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Confronting the History of a Southern Asylum: An Interview With Mab Segrest - Psychiatry Advisor