BOOK REVIEW

Psychiatry under the shadow of white supremacy

From the start, racism has shaped the care of people with mental illness in the United States. By Mical Raz.
Mical Raz is a physician and historian of health policy at the University of Rochester, New York.
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Patients sit on the edges of their beds and stare out of the windows in a dormitory at Milledgeville State Hospital

Patients at Milledgeville State Hospital, Georgia, in 1951.Credit: Robert W. Kelley/The LIFE Images Collection via Getty

Administrations of Lunacy: Racism and the Haunting of American Psychiatry at the Milledgeville Asylum Mab Segrest The New Press (2020)

How does a culture that enslaved people, encouraged lynching and developed racial segregation decide who is and is not sane? That is the question that frames Mab Segrest’s book on the legacy of slavery for US psychiatry in general and for what was in the 1940s and 1950s one of the largest psychiatric hospitals in the world.

Combining archival research with fictionalized scenes, Segrest, a feminist and anti-racist scholar, recounts more than a century of custodial care at Georgia’s infamous Milledgeville hospital for people with mental illness. It opened in 1842 and Segrest weaves its history with the wider trajectory of US psychiatric care, the ravages of the American Civil War (1861–65) and the many manifestations of white supremacy and violence against women.

The book is organized chronologically, but includes multiple forays into the present, which can be distracting. Segrest begins her account by reconstructing a period when slavery was omnipresent and the asylum took in only white patients. After the war, psychiatry followed a racist trajectory that was by no means inevitable, argues Segrest. When Milledgeville started taking black patients in 1867, it — like other asylums nationwide — adopted racial segregation.

As part of their treatment, white men worked as gardeners; black men had to labour on the institution’s farm. White women were seamstresses; women of colour worked in the laundry. Segrest uses the asylum’s archive to show that luxuries such as writing supplies, slippers, soap and carpets were allocated much more generously to white patients, whereas black patients faced daily discrimination and neglect. Many died soon after arrival, reflecting both their poor health and the deplorable conditions they had to endure.

Iron markers, displaced from graves over the years, stand in memorial of psychiatric patients buried at the Milledgeville asylum

Iron markers displaced from graves in the grounds of the Milledgeville hospital.Credit: Jaime Henry-White/AP/Shutterstock

Segrest also highlights what was left unexplored. Rather than asking how slavery might devastate an individual’s psyche, physicians treating newly freed African Americans discussed how their mental health might have been harmed by emancipation. What’s more, these patients often came from counties in which extreme racial violence, including “whippings, assaults, and murders”, was routine. Yet, in many cases, this history remained undocumented. Asylum psychiatry “maintained a vast silence about the bloodbath all around it”, writes Segrest, just as it had previously been silent about the violence of slavery.

Lingering effects

Milledgeville underwent several name changes and ultimately became the Central State Hospital before the main building closed in 2010. In her final chapters, Segrest examines how, when such hospitals began to close in the 1980s, penal institutions took their place. As welfare programmes were starved, the US prison population spiked, with people of colour and people with mental illness disproportionately incarcerated. Today, 90% of US psychiatric-care beds are in jails and prisons. Psychiatry will not be able to escape “the afterlife of slavery”, she argues, until it confronts its culpability in mass incarceration.

A newcomer to the history of psychiatry, Segrest’s approach is fresh and creative. She uses her imagination to flesh out the realities of life within the asylum walls. Describing Frances Edwards, a mother of seven taken to Milledgeville in 1856, Segrest imagines her arms feeling weirdly light and empty without her children, as her breasts “ached and leaked”. Segrest also finds connections between topics not always identified as part of psychiatry’s past. She calls attention to the high rates of infant mortality in the black community, exploring how such factors might have shaped — and still shape — black women’s mental health.

Segrest’s is one of several books in the past few years that have foregrounded discussions of race in the history of psychiatry and of asylums. Her impressionistic style and convoluted structure contrast sharply with the more rigorous work of historians such as Martin Summers in his 2019 Madness in the City of Magnificent Intentions and Wendy Gonaver in The Peculiar Institution and the Making of Modern Psychiatry, 1840–1880 (2019). Segrest’s mixture of fact and fiction can also be confusing.

But what is lost in clarity is perhaps gained in popular appeal. Uncomfortable reading at times, this valuable book helps to show how white supremacy shaped the definition and care of people with mental illness from the start, and how psychiatry remains in its shadow.

Nature 580, 449-450 (2020)

doi: 10.1038/d41586-020-01126-w

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