Mental health and ideals of citizenship: Patient care at St. Elizabeths Hospital in Washington, D.C., 1903-1962

In this thesis, I argue that U.S. psychiatry’s cultural project in the first half of the twentieth century was the reconstitution of mentally-distressed men and women for proper citizenship. This enterprise is visible on the wards, in the consulting rooms, and in the outpatient clinics of St. Elizabeths Hospital in Washington, D.C., one of the most widely-respected institutions of the era. Through an intensive analysis of patient care at St. Elizabeths, I identify two fundamental tensions in psychiatry’s cultural project. First, while physicians maintained high therapeutic aspirations for their patients, many of the men and women at the hospital received little more than custodial care. Second, despite the concept of citizenship’s egalitarian overtones, physicians at St. Elizabeths promoted a highly gendered and racialized vision of American life. By making it their mission to restore patients to a productive role in society, psychiatrists entered a contested terrain in which Americans continually refashioned the moral contours of U.S. citizenship. Originally founded as the Government Hospital for the Insane in 1855, St. Elizabeths embodied nearly all of the aspirations and contradictions of the nineteenth-century asylum. Not long after his arrival in 1903, superintendent William Alanson White articulated an expansive program for psychiatry in which shared values could be interpreted through the lens of mental health and illness. White identified psychological well-being primarily with the male social role, and his evolutionary framework paved the way for representations of black Americans as primitive and culturally atavistic. Patients experienced psychological impairment primarily as a form of civic estrangement, with unfamiliar patterns of thought and behavior undermining their ability to meet the obligations of American citizenship. While treatment at St. Elizabeths ran the gamut from individual psychotherapy to prefrontal lobotomy, most psychiatrists saw little overt tension between psychological and physiological rationales. If physicians could not restore all of the men and women under their care to independence, they hoped that patients would at least become “good institutional citizens,” capable of getting along with others and following the rules that governed their existence at the institution. The post-World War II era witnessed important changes in both psychiatrists’ vision of U.S. citizenship and the institutional culture at St. Elizabeths. Physicians took an increasingly liberal view of race relations under Winfred Overholser, who succeeded White as superintendent in 1937 and was prompted by national developments to integrate the hospital in 1954. These same psychiatrists promoted a restrictive domestic ideal for their female patients, in spite of the fact that middle-class married women were entering the labor market in unprecedented numbers. Physicians charted a cautious middle path in debates on homosexuality, maintaining that same-sex desires signified deep psychological maladjustment even as they protested policies criminalizing consensual sexual contact between adults. These developments occurred in the context of a general liberalization of institutional culture in the postwar decades. Through their own efforts as well as through innovations in clinical psychiatry, patients in the 1940s and 1950s found new opportunities for self-expression and began to articulate a novel sense of shared identity. By the time the major tranquilizers appeared, the appropriateness of long-term custodial care for psychologically-impaired men and women had already come into question