NINETEENTH-CENTURY ALIENISM WAS BORN IN THE ASYLUM, and throughout the first half of the twentieth century, most psychiatrists still practiced in institutional settings and dealt with those legally certified as insane. The years immediately before the First World War had seen the birth of the National Committee for Mental Hygiene (NCMH), the outgrowth of a campaign by a former mental patient, Clifford Beers, whose own mistreatment in a series of institutions, public and private, inspired him to launch an effort to reform the treatment of the mentally ill. Beers’s best-selling autobiography, A Mind That Found Itself, written in part while he was a patient at the Hartford Retreat and published in 1908, had made him a national celebrity and brought him into contact with Adolf Meyer.1 Meyer sought, without much success, to rein in Beers’s grandiosity, ultimately prompting a break between the two men. He suggested Beers should go to work as an attendant at the mental hospital run by his protégé Henry Cotton. Then, when Beers sought to launch a national campaign, he tried gently to persuade him to limit his ambitions to his native state of Connecticut. He succeeded in arousing Beers’s suspicion of his motives but not before he had planted the idea that, instead of trying to reform mental hospitals, Beers should focus on “mental hygiene,” the attempt to promote mental health and head off outbreaks of insanity.2
The estrangement deepened when Beers successfully sought funds for the NCMH from Henry Phipps, the industrial magnate who had funded Meyer’s clinic at Johns Hopkins. Beers saw his organization as acting on three fronts: campaigning to improve the care and treatment of those in mental hospitals; spreading the word that it was possible to recover from mental illness; and setting up programs to forestall mental illness and the need for hospitalization. For three years after the NCMH’s founding in 1909, financial difficulties limited its scope, but with the help of the Phipps money, eventually further funds were forthcoming from the Rockefeller Foundation. In 1912, an office was established in New York, and a new director, the psychiatrist Thomas Salmon, was recruited to run the organization. Two years later, the Rockefeller Foundation began to pay Salmon’s salary and to provide funds for national surveys of mental health issues.
The late entrance of the United States into the First World War had curtailed, but not prevented, the emergence of shell shock among the troops. Army medics found themselves treating both traumatic injuries to the brain and the central nervous system, and war neuroses of a far more mysterious sort. Though some continued to proclaim that the shell shocked were malingerers or degenerates whose underlying defects had surfaced under combat conditions, there was a growing acceptance that the horrors of combat were to blame. Madness, it seemed, was not just a condition found among the biologically inferior who thronged the wards of the asylum. It existed along a continuum, from psychoneurosis to psychosis, and early intervention in a noninstitutional setting might perhaps head off more serious forms of disturbance. Salmon’s brief period as an army psychiatrist in the closing months of the war had brought him into direct contact with victims of shell shock, and this helped cement his commitment to a psychiatry practicing outside the traditional asylums and to a program of mental hygiene, an effort to prevent mental illness.
If one adopted the Meyerian view that mental disorder was maladjustment, that meant that normal functioning, neuroses, and psychoses were simply variations along a continuum. It was a stance that opened up a far wider range of problems to psychiatric intervention. Juvenile delinquency, marital disharmony, crime, alcoholism, and so forth could all be viewed as psychological and thus medical problems.
To Salmon and his organization, the most promising way to head off insanity was to treat the young, an idea he soon sold to the first major foundation created by a woman, the Commonwealth Fund. Preventing juvenile delinquency became a major goal of the fund, conceived and financed by Mary Harkness, the widow of Stephen Harkness, John D. Rockefeller’s silent partner in Standard Oil. Child guidance clinics and marriage guidance clinics were established as new institutions that were to be the weapons in that fight. By providing advice on child-rearing and using suasion rather than harsh and punitive interventions, it was hoped that delinquency would be headed off.
With foundation money, demonstration clinics were opened, and some psychiatrists now found work outside the walls of traditional institutions.3 A handful of others found employment in industry, and a few more in the outpatient clinics that progressive states like New York, Pennsylvania, Michigan, and Massachusetts had begun to establish in the second decade of the twentieth century. The plan was to treat incipient cases of insanity among children and adults with advice and brief psychotherapy in an effort to slow or reverse the remorseless increase in the number of patients confined in state mental hospitals. In that regard, these programs were an abysmal failure, but they did mark a tentative effort by a small minority of psychiatrists to tackle what we now think of as “disordered thinking” before it manifested itself as overt pathology.4
Privately, some leading psychiatrists were scornful about the very notion of mental hygiene. Maxwell Gitelson, an early convert to psychoanalysis, commented that “its capacity for creating a need has developed far in advance of its capacity for meeting the developed need.”5 Even Adolf Meyer, whose ideas underpinned the movement, grew skeptical, complaining in a letter to a colleague of “the unfortunate noise and propaganda that has become necessary to maintain the salaries and professionalism of so many half-doctors and new ‘professions’ under the name of mental hygiene, and under the guise of unattainable panaceas.”6
Efforts to establish outpatient clinics in general hospitals were met with resistance or, more often, simply ignored. Hospitals had little interest in treating those exhibiting only mild symptoms of mental disorders, and also had little confidence that psychiatrists possessed the capacity to do so. A 1930 survey by the NCMH found that only 3 percent of the general hospitals responding made provision for psychiatric patients, and even that was likely an overestimate, given the tendency to conflate psychiatric and neurological conditions.7
Psychiatry’s efforts to break out of its institutional straitjacket thus enjoyed only limited success. Thomas Salmon left the NCMH in 1922 for a post at Columbia University. The following year, he became the first practitioner without a background in institutional psychiatry to assume the presidency of the American Psychiatric Association. But his death in a boating accident on Long Island Sound in 1927 silenced one of the main advocates for noninstitutional psychiatry.8 After his death, the Rockefeller Foundation began to distance itself from the NCMH, and privately Rockefeller staff voiced increasing mistrust and disdain for the whole mental hygiene enterprise. Alan Gregg, who had become director of the Division of Medical Sciences in 1930, spoke repeatedly in his official diary of his sense that “mental hygiene has been much oversold and expectations excited beyond likelihood of gratification”—a feeling that he found was “widespread” as he traveled around the country.9
THE YEARS OF THE GREAT DEPRESSION, however, witnessed developments that presaged the great changes that would overtake the profession in the aftermath of the Second World War. The first of these was the creation for the first time in America of a sizable presence of psychiatry in medical schools. Though Johns Hopkins had created some small space for academic psychiatry by appointing Adolf Meyer to head its new department, there were few signs of that experiment being replicated elsewhere until an enormously influential private foundation decided to devote its considerable resources to that task.
In the first decades of the twentieth century, the General Education Board of the Rockefeller Foundation had sought to transform American medical education, bribing and cajoling medical schools to reform their practices, and investing vast sums in universities that embraced its vision.10 It hoped to drive out of business the proprietary and substandard medical schools that were so notable a feature of the American scene in the nineteenth century—those whose admissions standards, laboratory facilities, and clinical instruction were so poor as to be beyond rescue. Ultimately, as many as a third of the existing schools closed their doors. The Rockefeller Foundation had considerable though mixed success in creating medical schools in the mold it sought, emphasizing biomedicine, the laboratory, and the production of new medical knowledge—to the detriment, some have argued, of the clinical care of patients.11
Unquestionably, the financial resources the Rockefeller Foundation mobilized had a transformational impact on American medical education. Since pharmaceutical companies had yet to enter the picture in any major way and government funding of universities and of medicine was essentially nonexistent—as it would remain until the Second World War ushered in the era of the imperial state—alternative sources of funding were few and far between. In the absence of the federal largesse that would soon underwrite research on disease, it was funding from the great private foundations that provided for such research equipment and support as universities could muster, and they underwrote the establishment of new specialized academic departments. In the medical arena, the Rockefeller Foundation was the preeminent actor. It was thus of great consequence when, in the late 1920s, the foundation shifted its focus away from the reform of American medical schools toward a much greater emphasis on research and the generation of new knowledge.
Two divisions were soon established to implement this new policy: a Division of Natural Sciences, headed by Warren Weaver from 1932 onward, and a Division of Medical Sciences, run from 1927 to 1930 by Richard Pearce and then by his deputy, Alan Gregg. In the early 1930s, Weaver and Gregg faced the task of setting the agenda for their respective divisions, subject to the approval of the Rockefeller trustees. For Weaver, a mathematician impressed by the advances in physics and chemistry that quantitative work had brought in its train, these priorities quickly became genetics and molecular biology. Gregg’s surprising choice was the highly unfashionable field of psychiatry.
The parlous state of psychiatry had not gone unnoticed even before the Rockefeller Foundation’s decision to focus on the field. In 1930, the foundation had solicited a memorandum from David Edsall, the dean of the Harvard Medical School and a trustee, to assist their deliberations. Edsall was hardly encouraging, noting that “traditionally, psychiatry has been distinctly separated from general medical interests and thought to such a degree that, to very many medical men it seems a wholly distinct thing with which they have no relation.” Nor was this state of affairs surprising: “In most places psychiatry now is dominated by elusive and inexact methods of study and by speculative thought. Any efforts to employ the more precise methods that are available have been slight and sporadic.” Edsall dismissed psychoanalysis as “speculative” and argued that any assistance to the field “would seem to have an element of real danger.… [I]t has a strong emotional appeal to many able young men, and I have known a number of men highly trained in science who began activities in psychiatry but, through the fascination of psychoanalysis, gave up their scientific training practically entirely for the more immediate returns of psycho-analysis.” He was equally dubious about the value of “the psychological or sociological aspects of psychiatry … romantic and appealing” as they might be.12
On taking up his position as head of the Division of Medical Sciences, Gregg had spent several months in conversation with a wide variety of psychiatrists: Meyer of Hopkins; his own brother Donald Gregg, who ran the exclusive Channing Sanitarium in the Boston suburbs (having married the founder’s daughter); W. G. Hoskins of the Worcester State Hospital in Massachusetts (whose work on dementia praecox was supported by a sizable grant from Mrs. Stanley McCormick); and Franklin McLean of the University of Chicago, among others.13 Edsall’s memorandum accurately reflected the skepticism most physicians had for psychiatry, but Gregg seems to have become convinced that this status as medicine’s ugly stepchild provided precisely the opportunity he was looking for. Psychiatry was, he granted, “one of the most backward fields of science. In some particulars, it was an island rather than an integral part of the mainland of scientific medicine.… [T]eaching was poor, research was fragmentary and application was feeble and incomplete.”14
Prudence might have argued for directing the foundation’s resources toward other fields with better prospects for advances. But Gregg decided to roll the dice and urged the trustees to make psychiatry the foundation’s top priority in medicine. It was a bold decision. His chances of success were greatly heightened by the fact that at least two leading members of the board had personal experience of serious mental illness. Max Mason, who was nominally president of the foundation from 1929 to 1936 (though his unsuitability led to his being largely sidelined), had been forced to institutionalize his wife for schizophrenia in the 1920s.15 Raymond Fosdick, who succeeded him, grappled with even more devastating circumstances: on April 4, 1932, his mentally ill wife had shot and killed their two children and then taken her own life—a tragedy that haunted him for the rest of his life.
The double murder and suicide were front-page news in the New York Times the following day. Fosdick traveled a great deal in the course of his work, and the Times reported that he generally stayed in a New York hotel when in town. The family had gathered together only for the Easter holidays. Fosdick slept through the shootings, only to discover the bodies on the morning of April 4. Diagnosed as manic-depressive, Winifred Fosdick reportedly “had been deranged for ten years” (the age of her young son), but lived next door to her parents and was being treated on an outpatient basis by a local Montclair doctor, Victor Seidler. Fosdick’s autobiography is largely bereft of references to his private life. The exception is a brief aside in which he acknowledges losing his wife and two children “in a moment of manic violence. The letters which my wife left behind her showed a mind completely out of touch with reality; she was far more ill than we realized even in the anxious years that preceded her death.… It takes time to recover from such a blow—if indeed one ever recovers.”16 It was perhaps no coincidence that, by the end of the year, the trustees endorsed Gregg’s recommendation.17
When Gregg spoke to the Rockefeller Foundation trustees in April 1933, he outlined the rationale for the priority he proposed to establish. The major reason to throw the foundation’s support behind the development of psychiatry and neurological science, he explained, was “because it is the most backward, the most needed, and probably the most fruitful field in medicine.” A few years later, justifying the first of several grants to Worcester State Hospital in Massachusetts, there was a note that of each dollar spent “for all state purposes twenty cents is consumed by the institutions for the mentally defective and diseased.” Worse still, “The present increase in Massachusetts of committed cases of mental disease is at a rate of 600 a year, requiring a new 2,000 bed hospital every four years.”18 Beyond this, the population of America’s mental hospitals was rapidly approaching 400,000 souls on any given day, and the mental health sector was the largest single element in many states’ budgets.19
A decade later, in a confidential memorandum to the trustees, designed to justify the fact that “approximately three fourths of the Foundation’s allotment for work in the medical [arena] is devoted to projects in psychiatry and related or contributory fields,” Gregg returned to these themes, emphasizing that the costs associated with mental illness were “tremendous and oppressive. In New York, for example, more than a third of the state budget (apart from debt service) is being spent for the care of the mentally defective and diseased.” This was clearly untenable. “Because teaching was poor, research was fragmentary and application was feeble and incomplete,” he suggested that “the first problem was to strengthen the teaching of psychiatry.”20
GREGG WAS RELATIVELY CLEAR-EYED about the difficulties associated with his choice. Though intrigued by psychoanalysis, he was not at first disposed to provide funding. He initially proposed to concentrate the foundation’s resources on the “sciences underlying psychiatry,” which he enumerated as including “the functions of the nervous system, the role of internal secretions, the factors of heredity, the diseases affecting the mental and psychic phenomena of the entity we have been accustomed erroneously to divide into mind and body.” The way forward was complicated by the fact that these were not medical specialties “in which the finest minds are now at work, nor in the field intrinsically easiest for the application of the scientific method.”21
Some historians have suggested that Gregg simply sought to draw on Meyer’s work at Johns Hopkins, having it serve as the basis for his new program.22 Certainly, Hopkins had by far the largest academic department of psychiatry in the country—indeed, some might argue that it was the only one that came close to matching the intellectual range and staffing that could be found in other areas of medicine at first-rate medical schools. It is also true that the term “psychobiology” was frequently bandied about when the Rockefeller officers discussed their support for psychiatry. But a useful turn of phrase by itself has little significance. There are ample grounds to doubt the claims that Meyer’s work underpinned the foundation’s support of psychiatry. Gregg and his colleagues provided funds to Horsley Gantt for work on Pavlovian ideas in relation to mental disturbances (financing his attempts, over a four-year period, to create neurotic dogs), and to Curt Richter for his pathbreaking research on such topics as the existence of an internal clock in humans and other organisms, as well as smaller sums to support Leo Kanner’s work on child psychiatry, but Meyer himself was not given much support, nor was his department.23 That remained the case even though Gregg recognized that Meyer was having to subsidize much of his operation from his clinical income and some rather odd donors, and was constantly short of funds.
The lion’s share of the Rockefeller money went toward underwriting a massive expansion of small and inadequate academic programs in psychiatry at major medical schools, or creating new departments from scratch. The support for Hopkins was dwarfed by the resources directed to Stanley Cobb’s work at Harvard (Cobb received five times as much as the Hopkins researchers put together). Psychiatry at Yale was funded still more munificently. In 1942, Gregg noted that the Rockefeller Foundation “has maintained the department since 1929 to the tune of $1,600,000.”24 Beginning in 1938, the foundation offered a further endowment of $1,500,000 to Yale on condition that it fund a fifty-bed psychopathic hospital for use as a teaching hospital. Yale temporized for years, and the foundation eventually lost patience and withdrew the offer.
Hopkins also received much less than the amounts directed to McGill, Rochester, Illinois, Duke, Tulane, Washington University in St. Louis, and Chicago, where entire departments of psychiatry were founded with Rockefeller money. Though some funds continued to be provided to individual researchers after Meyer’s much-postponed retirement in 1941, and Alan Gregg voiced initial support for the appointment of John C. Whitehorn as his successor, the foundation’s expectation that Whitehorn’s background in biochemistry and physiology would foster a closer engagement between psychiatry and the basic sciences proved misplaced.25
Setting research priorities was extremely difficult. The foundation’s solution was to fund an extraordinarily heterogeneous array of projects. Throw enough money at the problem, and one or more lines of inquiry would surely yield results. As early as the 1920s, Rockefeller money had flowed to Emil Kraepelin’s Munich institute and elsewhere, to fund research on genetics and mental illness. The accession of Hitler to power, and the growing racial dimension of this line of research brought about no change of heart, and money continued to flow to German researchers with a commitment to Nazi racial policies until the outbreak of war.
The recipients included the laboratory of Otmar von Verschuer—who counted Josef Mengele among his employees—and Ernst Rüdin, one of the architects of Hitler’s plans for mass sterilization and later extermination of the mentally ill. Rüdin’s activities were largely funded by the Rockefeller Foundation until 1939. Even after the war, Gregg awarded “a substantial series of grants to Franz Kallman for research on the genetics of schizophrenia.” Kallman, half-Jewish, had been forced to flee Germany in 1936, joining New York State Psychiatric Institute. While in Germany, he had proposed to extend the 1933 compulsory sterilization law, testing all relatives of schizophrenics for even minor anomalies and sterilizing any found to be “defective.” “The testing program would have been so massive, and would have involved the consequent sterilization of so many people, that it was considered impracticable even by the Nazis.”26
At Montreal, Gregg put large amounts of money behind a young neurologist and neurosurgeon, Wilder Penfield, and sought to bring together neurology, neurophysiology, and neurosurgery. At Harvard, large sums were mobilized to create a psychiatric service within a general hospital, while at Yale funds were found for everything from psychoanalysis to primate neurophysiology.
Neurotic disorders, seen as a less extreme form of mental disturbance than psychoses, were treated as a function of the autonomic nervous system on the one hand, and as examples of psychosocial maladjustment on the other. Gantt’s research on neurotic dogs at Hopkins was matched by Cornell’s program to study neurotic pigs and work on conditioned reflexes in sheep. (The latter proved particularly problematic because sheep “are so markedly gregarious that they cannot endure the loneliness of the laboratory alone and only perform satisfactorily when another sheep is tethered in the corner.”)27 George Draper of Columbia University was given money to examine the relationship between personality and body types. In other words, a thoroughgoing eclecticism characterized the way money was allocated, and the term “psychobiology” simply provided a convenient umbrella that lent some sort of spurious coherence to the whole.
ALTHOUGH THE TEENAGED ALAN GREGG had met Freud in the aftermath of his visit to Clark University, and Donald Gregg, his older brother, dabbled in psychoanalytic techniques at the Channing Sanitarium, the foundation at first shied away from Freud’s creation. A staff conference held on October 7, 1930, concluded that “psychoanalysis is in a stage of development where it cannot be attacked philosophically and can be left to its own devices—does not need money but needs maturity and needs defeat in places where it does not stand up.… Psychoanalysts are fighting enough among themselves to winnow out a great deal of chaff—nothing for us to do; but may not be dismissed as non-existent.”28
At just that moment, one of Freud’s closest disciples, Franz Alexander, had arrived from Berlin to lecture on psychoanalysis at the invitation of Robert Hutchings, the president of the University of Chicago. The lectures went very badly—Alexander called the visit “a fiasco”—and at the end of the year, he retreated to Boston to lick his wounds.29 By chance, during his time in Chicago, he had analyzed Alfred K. Stern, who had been suffering from a stomach ulcer that his sessions with Alexander apparently cured. Stern had inherited a banking fortune and had the good fortune to marry the daughter of Julius Rosenwald, the driving force behind the emergence of Sears Roebuck and one of the richest of Chicago’s plutocrats. He now became the sort of Dollar Onkel for Alexander that Freud had long fantasized of finding.
By 1932, Alexander was back in Chicago as head of the newly established Chicago Psychoanalytic Institute, a position he would occupy until 1956. Stern was installed as chair of its lay board of trustees, and with his assistance Alexander was soon raising funds from other wealthy Chicagoans and adding more former patients to his board. The presence of Alexander’s analysands as trustees ensured that he exercised almost complete power over the institute, which now became a center for psychoanalytic training in America. It was here that Karl Menninger and (more briefly) his younger brother Will gained their acquaintance with psychoanalysis.
Alexander thought he deserved the income and standing of a German Herr Doktor Professor, and paid himself accordingly. When he brought Karen Horney, another prominent refugee analyst from Berlin, to his staff in 1934, she too was paid handsomely as his deputy before they fell out, and she moved to Boston. Before the fallout, Alexander and Stern had succeeded in gaining an audience with Gregg. Gregg initially declined to fund the institute, indicating “he thinks it unwise to back a non-university Institute of Psychoanalysis at Chicago, where there is as yet not even a department of psychiatry.”30 Alexander and Stern were persistent, and finally, in early 1934, Gregg agreed to recommend that the Rockefeller Foundation provide assistance to the institute. In the end, the foundation awarded a total of $220,000 to the institute over an eight-year period. Some of the money was earmarked for psychoanalytic training, but the bulk was intended to support work on psychosomatic disorders.31 Alexander was shrewd enough to grasp that this emphasis was key to obtaining Rockefeller money.32 Gregg hoped that the study of psychosomatic illnesses would help create close linkages between psychoanalysis and mainstream medicine.33
As early as 1937, there were signs that Gregg’s confidence in Alexander was beginning to fray. He acknowledged that the training program seemed to be functioning, but he complained that “the physiological correlations they are attempting are not in competent hands” and the place seemed to be “a one-man show or at least rather too much dominated by Alexander.” With some hesitation, he recommended the renewal of funding for three to five years but insisted that any further support “should be based on a clear understanding of termination at the end of the period.”34 Alexander’s lifestyle and salary had begun to rankle. Gregg’s diary entry for December 8, 1938, records a conversation with Stern, where he expressed dismay with unnamed psychoanalysts who ought to be “prepared to further what they regard as the cause by a larger measure of personal sacrifice in point particularly of salaries.” The foundation would not provide “permanent maintenance” for such people. (Stern by now was no longer closely associated with the Chicago Institute and indicated that he concurred with Gregg’s assessment.) Gregg’s junior associates were even blunter. Robert Lambert noted: “I still don’t think much of the Chicago Institute crowd. Maybe Alexander has contributed a little something towards making psychoanalysis respectable but he certainly has not brought it into the scientific fold. I shall feel relief when the [foundation] award terminates—and is not renewed.” His colleague Daniel O’Brien concurred: “I have the same general hesitation as you about Alexander and some of the other people at Chicago.… Frankly, I would like to see the directorship of any institute of psychoanalysis turned over to, say, a sound physiologist or a good internist in medicine.”35
Over the next four years, Alexander’s lavish salary was the source of repeated negative commentary. Stern distanced himself from Alexander following his divorce from Marion Rosenwald and his marriage to the flamboyant Martha Dodd, daughter of the US ambassador in Berlin.36 Finally, at a tense meeting on October 31, 1941, Gregg rejected Alexander’s overtures. The psychosomatic research seemed to have led nowhere, and the salaries paid at the institute, partly with Rockefeller money, were “too large.” There was, he informed Alexander, “no chance” that he would recommend further support from the foundation.37
The only significant involvement of the Rockefeller Foundation with psychoanalysis in America thus came to an abrupt end. There were a few crumbs in grants to universities like Harvard, Yale, Chicago, and Washington University in St. Louis, but not much more than that. Even the flirtation with Alexander’s institute had cost less than 2 percent of the money the foundation used to underwrite American psychiatry. In 1934, when Gregg had received a proposal to provide support for an international institute of psychoanalysis in Vienna headed by Freud, he wanted nothing to do with it. The amount was small—$30,000 to $60,000—but the project struck him as worthless “in view of the present status of psychoanalysis,” in particular its “Cinderella position in point of academic status” and the fact that “Vienna as a locus has not optimum prospects from the standpoint of racial liberties.”38
And yet, without intending to do so, another branch of the Rockefeller Foundation had helped create the preconditions for the flourishing state of psychoanalysis in the United States. Beginning in 1933, and subject to much internal debate and hand-wringing, the foundation had started a program of “Special Aid to Displaced Scholars,” designed to help persecuted European scholars escape fascist Europe. It was this program, among others, that allowed almost 200 psychoanalysts and psychiatrists sympathetic to analysis to relocate to the United States. Refugee analysts would dominate psychoanalysis along the East Coast, and most especially in New York, and for a time constituted more than half the psychoanalytic community in the New World.