AMERICAN PSYCHIATRY IN THE YEARS after 1945 became a much more complicated beast than it had been until then. The landscape of academic medicine, and perforce of psychiatry, was irrevocably changed by the enormous expansion of the federal government and its growing involvement in funding scientific and medical research. No one was initially sure what the impact of agencies like the National Science Foundation, the National Institutes of Health, and the National Institute of Mental Health (NIMH) would be, but by the early 1950s, it was clear that America had entered the era of Big Science and Big Medicine and that the previous influence of organizations like the Rockefeller Foundation was waning. Even the enormous endowment of the largest private foundations was dwarfed by the resources that could be mobilized by the modern state, once the requirements of total war had broken the barriers to the expansion of the federal government.
The vast influx of federal dollars, initially to train new practitioners who were now deemed essential, provided a more stable underpinning for academic psychiatry and, with the benefits targeted at veterans, underwrote the rapid increase in the number of psychiatrists. The new practitioners opted, insofar as possible, to distance themselves from the traditional mental hospital and sought to provide outpatient services to a steadily more heterogeneous patient population, many of whom were at once less disturbed and far more affluent than those who had traditionally been institutionalized. Yet institutional psychiatry persisted, stigmatized and all-but-disowned by the glossy psychodynamic psychiatry, whose ambitions were directed elsewhere. The hundreds of thousands of psychotic patients, and the huge sums dispensed by the states to support the empire of asylumdom, ensured as much.
In the divided profession that now emerged, the largely unprecedented market for outpatient services expanded at a remarkable rate. Americans were used to paying for medical care as a commodity, and so the idea of paying for psychotherapy readily made sense. The war had helped promulgate the idea that mental illness and health existed on a continuum, and the psychiatric troubles of soldier-heroes had helped reduce some of the stigma surrounding the wide variety of psychological issues psychiatrists now claimed to treat.
Increased geographical mobility in the booming postwar economy and the baby boom meant that more and more parents had to learn to cope without being able to draw on an extended family network for help. Many turned to the first celebrity pediatrician, Benjamin Spock, for advice. The Commonsense Book of Baby and Child Care, first published in 1946, which would go on to sell over fifty million copies, translated Freudian ideas about neurosis into prescriptions for child-rearing, helping to indoctrinate a whole generation of young parents into the psychoanalytic perspective on life. Spock had been one of the first to train at the New York Psychoanalytic Society and Institute, and his devotion to Freudian ideas was lifelong.
His discussion of feeding infants, for example, revolved around the oral needs of the child. Contrary to the harsh and rigid approach to toilet training advocated by behavioral psychologists, he insisted that parents should take a casual approach, never shaming a child about soiling themselves, lest the youngster came “to dread all kinds of dirtiness” and became a fussy, finicky adult, obsessive about everything. Parents should likewise understand that it was quite natural that “boys become romantic toward their mother, girls toward their father,” and that their sense of possession will “at times [lead to] wishes that something will happen to” the parent of the opposite sex.1 These feelings, he assured the parents, help children to grow spiritually and to acquire wholesome feelings toward the opposite sex. But, of course, such sentiments must not be allowed to go too far or persist too long, so the parent must be at once understanding and firm. And so on. Freud was never mentioned, but his perspective was everywhere. Though the book began by urging parents to trust themselves, in becoming the authority figure relied on by millions of them, Dr. Spock helped popularize the notion that all sorts of troubles and distractions could be successfully addressed by professionals.
Hollywood also played an important role in presenting Freud’s ideas to a broad public. The film industry displayed an affinity for psychoanalysis from very early on, providing therapists a lucrative market for their wares. German and Viennese analysts dominated the Los Angeles scene from the start, and partly in consequence lay analysts from Europe were allowed to practice, something most American psychoanalysts viewed with dismay. The local clientele was not dissuaded, liking their therapists’ foreign accents and personal ties to Freud.
Acting is a deeply problematic profession, and the “talent” at the mercy of the Hollywood studio system frequently sought refuge on the analytic couch, as did more than a few directors. Even the Hollywood moguls, a shallow and venal lot, engaged the services of psychoanalysts. Samuel Goldwyn, convinced that Freudian sexual storylines could prove immensely lucrative and give a semblance of science and respectability to his movies, sailed by ocean liner in 1924 to Europe, determined to make Professor Freud an offer he couldn’t refuse. He planned to dangle a check for $100,000 if Freud would only become a screenwriter, only to discover that the great man declined even to grant him an interview. Other moguls sought therapy, either for themselves, for the wives they had betrayed on the casting couch, or for the children they ignored. David Selznick, unexpectedly gripped with depression after the overwhelming commercial success of Gone with the Wind in 1939, tried a few sessions himself before giving up and returning to amphetamines and sex. He then sent his wife, Irene, daughter of his great rival, Louis B. Mayer, to the analyst he had tried, May Romm. His wife learned enough to dump him but soon found herself sharing an analyst with one of her husband’s many mistresses and her replacement, the actress Jennifer Jones (who married Selznick once she had rid herself of her previous husband).2
The success psychoanalysis enjoyed behind the camera was soon replicated in front of it. Moss Hart’s Lady in the Dark, a musical comedy about the heroine’s psychoanalytic treatment, was successfully transferred to the screen in 1941, and in the war years, films with psychoanalytic themes regularly rolled off the production line. In the war’s immediate aftermath, Alfred Hitchcock’s Spellbound marked perhaps the most unembarrassed exploitation of Freud’s ideas in the service of popular entertainment. As the titles roll, viewers are informed that the “story deals with psychoanalysis, the method by which modern science treats the emotional problems of the sane. The analyst seeks only to induce the patient to talk about his hidden problems, to open the locked doors of his mind. Once the complexes that have been disturbing the patient are uncovered and interpreted, the illness and confusion disappear … and the evils of unreason are driven from the human soul.”
Produced by the inimitable David Selznick, who insisted that Hitchcock use May Romm as a consultant, the film exploits the parallels between the work of a detective solving a crime and the role of psychoanalysis in unpacking the hidden layers of the self and past. The solution to the murder mystery depends on the rediscovery of repressed memories by its heroine and her teacher, and a key explication of some of the plot’s central puzzles lies in the symbolism of dreams, re-created on the screen (again at Selznick’s insistence) by Salvador Dali.
Commercially successful, the film was probably the most overt attempt to educate the masses about the wonders of the talking cure. It was scarcely the last movie to embrace psychoanalytic themes.3 In 1948, The Snake Pit, the highest-grossing film of the year, provided a portrait of a disturbed young woman committed to a dreadfully overcrowded state hospital (a realistic starting point) who is cured by a dedicated psychoanalyst who mysteriously finds the time to use the talking cure, with great success. Suddenly Last Summer (1959) employs a similarly sympathetic depiction of the use of analysis to rescue Elizabeth Taylor from a looming lobotomy. Beyond that, viewers of Rebel without a Cause (1955) and Psycho (1960) were left in little doubt about the sources of pathology and the linkage of adolescent delinquency and adult crime to Freudian family tangles. Hollywood’s worship of psychoanalysis continued through I Never Promised You a Rose Garden and Robert Redford’s 1980 directorial debut, Ordinary People, and beyond. Psychoanalytic influence in popular culture was matched among intellectuals. Humanists and social scientists both found Freud’s ideas fascinating.
BEYOND A CORE GROUP of officially certified analysts, many who lacked the imprimatur of the established institutes practiced what they termed “psychodynamic psychiatry” on an outpatient basis. In the postwar years, intellectuals across the humanities and social sciences pronounced themselves Freudians, and the first director of the newly established National Institute of Mental Health, Robert Felix, endorsed psychosocial perspectives on mental illness in the most practical of ways: through federal grants underwriting the training of would-be practitioners. Federal research money was also directed to a broad array of projects exploring the psychological and sociological dimensions of mental disorders.4
Emboldened by the rapid growth in their numbers, Freudian analysts and their allies took on the old guard, the psychiatrists who still made their living in the state mental hospitals, ministering to the largely impoverished and stigmatized clientele who thronged their wards. William Menninger, whose prestige was at its height after his wartime service, and who found working alongside his older brother Karl in Topeka intolerable, was the chosen candidate of the upstarts. There had been simmering disputes between the brothers all through the 1930s, which Will’s absence had temporarily alleviated, but Karl’s authority as the older brother was eroded by the successes Will had enjoyed in Washington and the national prominence it had brought him.5 The jealousy, the petty slights, the barely suppressed hostility each displayed toward the other were perhaps not the best advertisement for the value of psychoanalysis in reconstructing human personalities, but they were intense and threatened the very future of the Menninger Clinic. William Menninger’s activism on the national stage, and his subsequent absences fundraising for their joint enterprise, kept some sort of check on what otherwise promised to be a poisonous atmosphere. He was persuaded, with some show of reluctance, to run for president of the American Psychoanalytic Association, a position he took up in 1946.
Menninger’s hesitations about taking that job reflected his odd and marginal relationship to classical analysis. His own didactic analysis with Franz Alexander had been brief and unsatisfactory, and the experiences of the next decade had left him even more disenchanted. As he confided to his brother Karl in 1939, “I don’t know of any medical group in any place that has as many ‘queer birds,’ and eccentric individuals in it as the psychoanalytic group. The fact that this has been augmented now by a lot of emigrants only adds to the bizarre nature of this whole group. For that reason, I don’t feel any great urgency to identify myself too closely with them.”6 His experiences during the war with psychotherapy had modified but not entirely altered these critical views. And yet the training manual he wrote to systematize the training of army psychiatrists, with the inauspicious title of War Department Technical Bulletin No, 203, was full of psychoanalytic language, and its diagnostic categories displayed a heavy Freudian influence.
His ambivalence about assuming the presidency of the American Psychoanalytic Association was not feigned. Indeed, Menninger initially wrote a speech declining the nomination, noting that for years he had had “little contact with the Association’s organization and affairs,” deterred by its reputation for “discord, disharmony, sectional squabbles and professional disagreements.”7 But when pressed to change his mind, he relented, for reasons that soon became clear.
IT SHOULD OCCASION NO SURPRISE that the analytic community was eager to trade on the greater visibility the war had given to its doctrines. Its new president, however, sought to use the platform his position supplied to push psychoanalysis in a more ecumenical direction. The postwar mental health needs were so great, he contended, and the supply of analysts so inadequate, that the strict boundaries that separated psychoanalysis from mainstream psychiatry ought to be relaxed. Membership ought “to be opened to interested physicians and social scientists and … training programs … established for psychiatrists in psychoanalytic applications of psychotherapy.”8
It was a heretical idea the membership promptly vetoed. While Franz Alexander, whose institute in Chicago had already strayed from orthodoxy, endorsed the idea of weakening the barriers between psychoanalysis and other forms of psychotherapy, a parade of the orthodox and their allies—such prominent figures as Ernest Jones, Kurt Eissler, Heinz Hartmann, Phyllis Greenacre, and Rudolph Loewenstein—denounced any attempt to deviate from psychoanalytic truth and Freud’s legacy. Rather than endorse Menninger’s appeal, on taking his post, “to develop a united front and a spirit of unity towards the enormous jobs to be done that must eclipse personal differences and sectional disagreements,” the assembled members voted to make the criteria for membership even more stringent.9
Rebuffed on this front, Menninger tried another tack. The American Psychoanalytic Association (APsA) and the American Psychiatric Association (APA) had for some time arranged to coordinate their meetings. Taking advantage of this opportunity to exchange views with like-minded figures in the analytic community, Menninger sought to realize his vision of a socially active, psychodynamically oriented profession by turning to the much larger organization, the APA, and bending it to his vision. Together he and his allies—one of whom, significantly, was the director of the NIMH, Robert Felix—formed a pressure group intended to serve as the catalyst for change in the APA. They called themselves the Group for the Advancement of Psychiatry (GAP).
Membership was to be limited to 150 psychiatrists committed to a thoroughgoing reform and expansion of the professional association, which had hitherto largely confined itself to the publication of an academic journal, the American Journal of Psychiatry; and to an annual meeting whose primary purposes often seemed social rather than scientific.10 GAP sought to change all that, advocating for a sharp increase in dues, the appointment of a full-time medical director, and an outright expansion of the association. Its broader ambition was to serve, in Menninger’s words, as a “mobile striking force for American psychiatry.”11
In its early stages, GAP’s single-minded pursuit of its objectives proved remarkably successful. Those committed to Menninger’s vision of an eclectic, psychodynamically oriented psychiatry were drawn, in many cases, from the ranks of military psychiatry, along with leading figures from academic psychiatry, which the Rockefeller Foundation had done so much to bring into being. GAP members had prestige and a shared contempt for the backward world of institutional psychiatry, but as yet they were but a minority of the profession. When they secured William Menninger’s election as president of the APA in 1947, they only did so because the traditional wing of the profession split its votes between two other candidates, Nolan Lewis of the New York Psychiatric Institute and Arthur Noyes, superintendent of the Norristown State Hospital. In the three-way race, Menninger won with only 41 percent of the total votes, making him simultaneously the president of both the APsA and the APA. GAP members occupied four out of the five positions on the APA Executive Committee and also constituted two-thirds of its council. The association’s newly appointed full-time medical director was also a member.
There was ample reason for state hospital psychiatrists, still the majority of the profession, to be alarmed by these developments. Virtually without exception, GAP members were psychiatrists who had no contact with the world of the asylum and who viewed those working there as the most backward members of the profession. Events over the next few years only heightened their concerns, creating a polarization so acute that for a time, in Gerald Grob’s words, “the very existence of the APA was called into question.”12 Seeking to reassert their control over the APA, the hospital psychiatrists who sat on the nominating committee put forward a single candidate for the presidency to succeed William Menninger in 1948.
CHARLES BURLINGAME was the superintendent of the Institute of Living in Hartford, Connecticut, an exclusive asylum for the very wealthy. He was closely allied with his state hospital brethren and, like them, an enthusiastic proponent of biological psychiatry and of the various somatic treatments that had emerged in the 1930s, from insulin comas and electroshock to lobotomy. Indeed, he had just opened the first specially designed operating theater to lobotomize those of his “guests” who were suitable candidates for psychosurgery. In a speech subsequently published in the Journal of the American Medical Association, he spelled out his allegiance in no uncertain terms, suggesting that “only a stupid person would decry” lobotomy and the shock treatments. As for psychotherapy, it stood alongside the occult and threatened to bring the whole profession into disrepute. The traditionalists quite naturally considered him an ideal candidate to put GAP and its allies in their place. The nonsense GAP was peddling was going to be set to one side, and the medical and biological identity of the profession reaffirmed.13
But at the 1948 convention, the institutional psychiatrists found themselves outmaneuvered. Dexter Bullard, the director of the psychoanalytically inclined Chestnut Lodge, considered advocates of lobotomy like Burlingame to be criminals who assaulted and irretrievably damaged the patients in their care. Though not a GAP member himself, he served their purpose by nominating an alternate candidate from the floor, George Stevenson, medical director of the National Committee for Mental Hygiene, a man known for his “progressive” views and his political connections in Washington.14 From his early work helping to set up child guidance clinics in Minnesota to his years of bureaucratic service in Washington, Stevenson had little direct contact with patients of any sort, and even less with those immured in mental hospitals. His links to the Menningers and their allies had solidified during the war years, and he had played a behind-the-scenes role in drafting the legislation that created the NIMH. In other respects, though, he was an unpromising candidate. As one of his contemporaries noted, in Stevenson’s obituary no less, “He was not a colorful character, never smoked or drank and had no small talk or casual conversation … and little sense of humor or ability to laugh at the foibles of mankind.”15
It was thus not Stevenson’s personal qualities that prompted his nomination, or his charisma that brought him victory against his gregarious opponent. Voting was confined to the delegates in attendance, and GAP had packed the proceedings with supporters, while many hospital psychiatrists, convinced that the election was a foregone conclusion, had neglected to attend. Their complacency turned out to be a grave mistake. Though institutional psychiatrists constituted the majority of the profession, Stevenson won the presidency by 389 votes to 342.16
If that were not bad enough, GAP had set up a number of subcommittees, and several of them began to issue reports that were highly critical of state hospital practices. From September 1947 onward, GAP published a series of bulletins purporting to assess various psychiatric therapies. These were the somatic interventions that were the standard recourse of those practicing in mental hospitals, whose outlook and interventions many members of GAP despised.
The first report GAP issued, in September 1947, was highly critical of electroconvulsive therapy (ECT). Doubt was cast on its therapeutic value, and complaints were voiced about the “overemphasis and unjustified use of electro-shock therapy.”17 A subsequent report on lobotomy was equally critical. Those severing the frontal lobes of their patients were portrayed as irresponsible actors, out of touch with modern psychiatry. Lobotomy, its authors wrote, “represents a mechanistic attitude toward psychiatry which is a throwback to our pre-psychodynamic days.”18 Robert Knight, who had served as chief of staff at the Menninger Clinic before moving to a similar position at Austen Riggs in Massachusetts, brought these criticisms to the lay public via the pages of the New York Times, assailing “the indiscriminate use of ‘strong-arm’ methods of psychotherapy such as electroshock, injections of sodium amytal and lobotomy.” A “pernicious” attitude had spread among many of his colleagues that “the patient’s illness must be beaten out of him,” and the profession had been “prostituted” by those who “know no other methods” and “think only of making the patient give up his complaints and subside.”19
If their aim was to provoke an angry response from traditional psychiatrists, the members of GAP certainly succeeded. Mental hospital psychiatrists who had initially responded facetiously to the creation of GAP by forming a group of their own dubbed GUP—Group of Unknown Psychiatrists, or Guppies—were now furious. They formed a more serious organization and called themselves the “Preserves,” psychiatrists committed to biological psychiatry and somatic treatments. There was open talk of secession, along with mobilization against the analysts and their allies. The structural divisions between academic and office-based psychiatry, and those who had charge of the now half-million patients in mental hospitals, threatened an irretrievable rupture of the whole enterprise. So fierce was the counterreaction that Menninger led a hasty retreat, adding a major proponent of ECT—Lothar Kalinowsky—to GAP’s committee on research, and announcing that the report would be revised in a more balanced form. A compromise candidate was put forward to succeed Stevenson as the APA president, Adolf Meyer’s colorless successor at Johns Hopkins, John C. Whitehorn, a man guaranteed to accomplish not much.
GAP’S INITIAL CRUSADES now began to founder. Menninger and his circle had propounded plans for a much broader role for psychiatry in public life, vetting the psychological stability of candidates for public office, applying psychoanalytic insights to the conduct of foreign policy, and reworking “education, industry, recreation” to improve the community’s mental health. In many ways, these claims mimicked those made earlier in the century by the proponents of mental hygiene (and Karl Menninger’s suggestion in 1940 that it was time for psychiatry to broaden its attentions “beyond a hapless and hopeless few”).20 And like the programs put forward by their predecessors, these suggested social and political interventions mercifully had no substantive content.
They collapsed accordingly in short order. William Menninger kept preaching these doctrines till his death from cancer in 1965, but he cut an increasingly forlorn figure, periodically showing up at the offices of the Rockefeller Foundation and the Commonwealth Fund seeking seed money to implement broad-ranging psychosocial programs at the Menninger Clinic.21 The Commonwealth Fund had been skeptical of the Menningers’ plans even during the 1940s, and though they did not formally reject the proposals they received, neither did they fund them.22 Internally, the staff was dismayed by the quality of the annual reports forwarded by the Menninger Clinic. One wrote that “even the most conscientious reader is left in a state of bewilderment regarding the accomplishments of the Menninger Foundation.”23 Efforts in 1958 to get support for a marriage counseling service were rebuffed. In 1963, and again in 1964, William Menninger solicited support directly from Malcolm Aldrich, the president of the foundation, and was spurned.24 For some time, his residual reputation ensured that he was received before his supplications were politely rejected. Eventually, however, exasperated foundation officers begged him not to bother. No money would be forthcoming, so he was asked, in so many words, not to waste their time: “as we told Miss Crim, however, there is no possibility of being of further assistance in the foreseeable future.… Under the circumstances I thought it was only fair to let you know the situation so that you would not make a needless call when I know your time in the city is limited.”25
In the new landscape created by the growing intervention of the federal government in the mental health arena, the Rockefeller Foundation had already embarked on a major reassessment of its commitment to psychiatry. Government programs embraced a very different approach to funding psychiatry (and medicine and science more broadly) than the one the foundation had relied on to dispense its funds. The foundation preferred to pick out prominent and up-and-coming scholars, relying on the instincts and personal judgments of its officers in making its decisions. Its model was now being challenged by something approximating a peer-review system. Within less than a decade, the resources Washington could provide swamped those that could be offered by private philanthropy and entrenched this very different approach to assessing funding priorities.
The long tenure of Raymond Fosdick as the Rockefeller Foundation’s president ended in 1948. His replacement, the management theorist Chester Barnard, immediately launched a major review of the foundation’s priorities, questioning what its massive investments over the preceding two decades had accomplished. In the case of the Natural Sciences Division led by Warren Weaver, the answer was quite reassuring. Weaver had coined the term “molecular biology,” and the grants he had administered had largely created the field.26 The technologies, laboratories, and scientists Weaver had funded had proved their worth in the just-concluded war, and his own activities in organizing the Applied Mathematics Panel, created to solve mathematical problems related to the wartime military effort, had further cemented his reputation. His investments looked sound and would have massive payoffs in the next decade. Of the eighteen molecular biologists who received a Nobel Prize between 1954 and 1965, fifteen had received funds from the Rockefeller Foundation, and they had received their first support beginning on average nearly two decades earlier.27 Barnard could feel assured that the Natural Science Division grants had been money well spent.
What about Gregg’s program in support of psychiatry? Here, matters were more complicated. The various somatic therapies—malaria therapy, insulin comas, metrazol, ECT, lobotomy, and the like (still mostly seen as having some therapeutic value)—had all originated in Europe and owed nothing to Rockefeller funding. Nor could Gregg and his team point to any other breakthrough that could be traced to their investments. In 1944, Gregg had acquired an able deputy, the neurophysiologist Robert Morison, and four years later, Morison attempted a survey of the state of psychiatry. What he confronted was the inescapable reality that “a generation of funding [had] yielded painfully little in tangible results.”28 Morison’s report did not make for very encouraging reading. Of the approximately $16 million in grants to psychiatry between 1931 and 1946, only about a quarter went to departments that already existed, and little of that money went for research. Nearly a half had been spent on “establishing entirely new or to expanding negligibly small university departments of psychology or psychiatry.” What had all this wrought? Morison could point to some progress in the treatment of epilepsy and some “slow but steady progress … in the understanding of the elementary functions of nervous tissue. But the total is not distinguished or dramatic.” Still, he somewhat unconvincingly concluded, ”a sound beginning has been made.”29
In August 1948, Barnard sent a sharp memorandum to both Gregg and Morison stemming from his reading of the latter’s diary and commentary on the state of psychiatry. (Diaries at the Rockefeller Foundation were not private documents but internal records that circulated widely among the officers and were meant to inform policy.) The portrait of the state of psychiatry Morison presented was something he found “terribly disturbing, [though] somehow it wasn’t terribly surprising to me. Isn’t there a way,” he asked, “to blast this situation?”30
Morison complained on multiple occasions that the profession’s heightened emphasis on psychotherapy had not been accompanied by any effort to test the efficacy of such forms of treatment. Instead of looking for ways to address the issue, psychiatry’s leadership, now increasingly consisting of psychoanalysts, seemed to throw up its hands, declare the problem beyond solution, and rely on anecdotal evidence. Barnard was unimpressed. Rather sharply, he confronted his officers: “Doesn’t a continued and general refusal to permit or attempt validation of psychotherapeutic methods put everyone concerned, including ourselves, in a position of promoting or carrying on a social racket? How can the charlatans be dealt with if the good men will give no validation but their own individual say-sos?”31
A month and a half later, having consulted with Gregg, Morison attempted to answer these pointed questions. His diary entries, he noted, were “to be regarded as a collection of data relevant to the present situation but not necessarily a complete or conclusive description of it.” But what followed cannot have made very reassuring reading. Medicine, Morison claimed, had long displayed an almost complete neglect of “the less easily analyzed psychological factors.” Combined with “the very rapid increase in scientific knowledge about the organic elements in disease,” the upshot was that “the prestige of psychiatry, which had never been very high, declined almost to a disappearing point during the Twenties and Thirties.” There had, Morison hastened to add, “been an extraordinary change,” “due in part to the interest” of the Rockefeller Foundation. Faced with their professional marginality, “the younger generation of psychiatrists have naturally devoted a large proportion of their energies to gaining acceptance on the part of the rest of the medical profession.”32
How had they done so? “Since their art was too primitive to be defended on the basis of scientific evidence, psychiatrists have relied largely on rhetorical persuasion in their campaign for recognition. A large part of this persuasiveness has rested upon the revelatory nature of Freudian concepts.” This scarcely advanced Morison’s defense of the profession very far, as he was immediately forced to concede the limitations of this approach. “It is certainly very difficult to give in any clear and simple way one’s reasons for believing that the basic Freudian hypotheses are correct,“ he conceded. The best he could offer was that “there is no question in my mind … that the concept of unconscious motivation has enabled us to understand the meaning of psychiatric symptoms which have hitherto been incomprehensible.” But understanding their meaning was not the same as deducing their cause. Morison argued that the acceptance of psychiatry was more tenuous than most practitioners realized. The rest of medicine was still waiting “for evidence of the sort which has validated, for instance, the use of antibiotics. If this is not forthcoming within the next ten to fifteen years, [physicians] may react rather violently, partly out of embarrassment for having extended a welcoming hand to a group which finally failed to produce.”33
Toward the end of his lengthy assessment of the state of psychiatry, Morison provided direct evidence of the problems he had identified. His focus was a recent report prepared by GAP’s research committee on psychotherapy. As he pointed out, this document spent a lot of time talking about “the intrinsic difficulty of doing research in psychotherapy … [and] seems more concerned with explaining why it is impossible to do a good job of validation than to find ways of circumventing the difficulties. It would be so much more comfortable if one could only maintain the status quo of acceptance on rhetorical grounds rather than risking the whole reputation of the art by submitting it to scientific study.” There was, however, something even more worrisome to which he drew Barnard’s attention: “the ease with which the Group for the Advancement of Psychiatry has adopted the committee approach to situations of this sort. There have been several times recently when I have felt that the leaders of American psychiatry are trying to establish the truth on the basis of majority vote. This is, of course, quite contrary to the usual scientific procedure of submitting evidence which can stand on its own merits in a candid world.”34
Voting would remain a device that organized psychiatry would resort to all the way down to the present. It would be the basis, for example, on which the profession would decide in 1973 that homosexuality was no longer a mental illness; and it has underpinned each successive appearance of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) from the third edition of 1980 all the way down to the fifth edition of 2013.35
The skeptical Barnard must have wondered whether the decision to focus the foundation’s efforts on remaking psychiatry had been a terrible error. Morison immediately sought some way to avoid such a devastating judgment: “I very much hope that this frank statement of my misgivings about current trends in psychiatry will not give the impression that I feel we have made a mistake in helping these trends to develop,” he wrote. “There is absolutely no doubt that something had to be done fifteen years ago to increase the medical interest in psychiatry and to recruit and train personnel. One had to begin somewhere, and it was impossible to start on the basis of tested scientific knowledge.” Perhaps conscious that statements like this risked damning the whole program with faint praise, Morison now changed tack. Contrary to the impression his previous remarks surely would have given, he insisted that, looking at the program as a whole,
The gains so far have really been surprisingly large. For example, it is really of immense importance that the oncoming generation of medical students is being shown that the emotions play an important role in almost all their patients. It is equally significant that there is now a large group of able young men who have been attracted to the field of psychiatry and who may, if properly handled, be able to take the necessary next step. I therefore do not feel that we are supporting a racket when we continue to aid psychiatry in its present, admittedly imperfect state.36
It was, in any event, no time for “blasting,” but rather for “some less drastic handling,” perhaps a shift away from psychiatric teaching toward a greater emphasis on research.
Four years later, in an interoffice memorandum, Morison lamented that “most [psychiatrists] refuse to recognize that the brain may have something to do with the mind.” His hopes that the profession’s opposition to research on the efficacy of psychotherapy would diminish with time had dimmed. He feared that the “the development of research has lagged badly so that psychiatric practice is still without a scientific foundation.”37 Perhaps the division should move in a different direction. And with that, with a whimper more than a bang, the Rockefeller Foundation essentially exited from its support of psychiatry.
In March 1951, aware that his authority was at an end and that the foundation was moving on, Alan Gregg wrote to Chester Barnard and asked to be relieved of his position as director of the Medical Sciences Division. Barnard proceeded to merge the International Public Health Division and the Division of Medical Sciences into a single entity, and he put Gregg’s former deputy, Robert Morison, in charge. A fig leaf was found for public relations purposes to salve Gregg’s pride—he was appointed vice chair of the foundation and was charged with writing and speaking about medicine and its broader role in society. He joined various boards and traveled the country, and then in 1956, at the age of sixty-six, foundation policy forced his retirement. A year later, he was dead.
THOUGH GAP HAD BEEN A MAJOR FORCE in psychiatry when Chester Barnard had begun his inquest into what the Rockefeller Foundation’s support for psychiatry had accomplished, it was virtually a spent force by the time of Gregg’s death. Its demise went unmourned by institutionally based psychiatrists. In the short run, their counteroffensive had headed off their worst fears. Yet in the long run, their fate was sealed. Demographically, the psychiatrists working in the state hospitals were swamped as the numbers of academic psychiatrists and the ranks of those practicing outpatient psychiatry grew. By 1957, only 17 percent of psychiatrists practiced their trade in state hospitals.38 This rapid shift in the profession’s center of gravity occurred in the context of an extraordinary expansion in its absolute size. From fewer than 5,000 APA members in 1948, the association’s ranks had risen to more than 27,000 by 1976.
Institutional psychiatrists were badly paid public employees ministering to a largely impoverished and heavily stigmatized patient population, few of whom seemed destined to recover. Their situation contrasted badly with the privileged lives of the professors, and even more so with that of successful psychoanalysts, whose incomes were two to three times those of state hospital psychiatrists and who could inhabit vibrant urban centers and weren’t confined to the rural backwaters where asylums were mostly to be found.
Freud’s ideas were everywhere in postwar America, reinforced in newspapers and magazines, in popular works of anthropology and sociology, and in novels and movies. New psychiatrists were trained not as they had once been through apprenticeships in state hospitals, but in university departments using textbooks that increasingly emphasized Freudian accounts of the origins of even the most serious forms of mental disorder. Textbooks such as Practical Clinical Psychiatry, which had once hewed to a Meyerian line, now embraced psychoanalytic ideas, as did the two-volume American Handbook of Psychiatry, which provided passing reference to other approaches but was fundamentally a psychoanalytic text. The second edition of Silvano Arieti’s Interpretation of Schizophrenia even succeeded in reaching an extra-professional audience, winning the 1975 National Book Award for Science.39 Though Arieti’s suggestion that analysis was the preferred treatment for schizophrenia was a minority view, his claim that pathological families were responsible for creating pathological children became the orthodoxy of the day.
THE ASYLUM MIGHT HAVE BEEN THE SOCIAL SPACE that gave birth to modern psychiatry. Increasingly, however, those who practiced within its walls were the profession’s marginal figures—if not quite ostracized, then largely ignored. The impact of the Great Depression on state budgets had been massive, and since mental hospitals constituted the largest, or second-largest, item in most states’ expenditures, they fared poorly in the 1930s, a situation compounded by the fact that poverty and want drove increased numbers into these institutions. Then came the war, which deprived the mental hospitals of many of their staff, crimping budgets even further. Desperately short of attendants (to say nothing of doctors and nurses), mental hospitals had filled some of their vacancies by employing conscientious objectors.
Educated middle-class men exposed to the appalling conditions in which nearly half a million fellow citizens were kept reacted with horror to what they observed. After the war, some 2,000 of them collaborated on a best-selling exposé, Out of Sight, Out of Mind, a litany of vivid stories reporting, in the words of its editor, a nightmare world of “Inadequacy, Ugliness, Crowding, Incompetence, Perversion, Frustration, Neglect, Idleness, Callousness, Abuse, Mistreatment, Oppression.”40 A photo essay published the year before in the mass-circulation magazine Life had printed some of the pictures smuggled out of hospitals by conscientious objectors. Two of them, taken at Byberry State Hospital in Philadelphia by the Quaker Charles Lord, were particularly shocking. One, of the male incontinent ward, pictured nude men, some slumped on the floor, others picking their way across a concrete floor amid puddles of urine and piles of excrement. A second was of a ward for violent men, known to the attendants as “the death house.”41
Journalists, some of whom had just returned from Europe, where they had visited Nazi concentration camps, compared the back wards of American mental hospitals to the death camps they had seen.42 Unlike the Nazis, they noted, the United States had not directly set about killing the mentally ill. Under Hitler, the so-called T-4 program had murdered more than a quarter million mental patients, with the active and enthusiastic participation of many of Germany’s leading psychiatrists, eager to relieve the Third Reich of those they contemptuously referred to as “useless eaters.” Instead, American institutions neglected and half-starved their patients, relying on nature to take its course.
Perhaps the most widely read of these exposés was a series of newspaper articles on conditions in mental hospitals all across the United States, subsequently published in book form in 1948 as The Shame of the States. Its author, the journalist Albert Deutsch, had written the first history of the treatment of the mentally ill in America, a glowing account of how reformers had rescued the mentally disturbed from brutality and neglect in the community, and from confinement and cruelty in jails, to which most of the mentally disturbed had previously been sent. That book was an uplifting story of the passage from ignorance and superstition to enlightenment and science, so congenial to the nation’s psychiatrists that they had promptly made its author an honorary member of their association. It might seem paradoxical, then, that its author, of all people, should pen a notably harsh critique of the state of mental hospitals in the postwar era. The fact that the foreword was written by Karl Menninger, and that Deutsch fulsomely praised GAP in his concluding remarks, might suggest that Deutsch had become a critic of institutional psychiatry and come to side with the psychoanalysts. But that conclusion would be badly mistaken.
Deutsch’s book provided a series of detailed reports of what he had seen as he had visited a dozen mental hospitals, many of them in liberal northern states that supposedly provided the best public psychiatry. His descriptions were chilling. Everywhere, patients were housed in decayed and overcrowded facilities, bereft of even a semblance of therapy. Beds were crammed together, sometimes stacked two and three high. Food was abominable. Brutality and neglect were rife, with much of the violence inflicted by the attendants: “As I passed through Byberry’s wards, I was reminded of the pictures of the Nazi concentration camps at Belsen and Buchenwald. I entered buildings swarming with naked humans herded like cattle and treated with less concern, pervaded by a fetid odor so heavy, so nauseating, that the stench seemed to have almost a physical existence of its own. I saw hundreds of patients living under leaking roofs, surrounded by moldy, decaying walls, and sprawling on rotting floors for want of seats or benches.” Byberry, Deutsch noted, had more than 6,100 patients in buildings meant to house no more than 3,400.43
Byberry was the first mental hospital Deutsch visited. The rest were as bad or worse. He was oppressed by “the deadly monotony of asylum life, the regimentation, the depersonalization and the dehumanization of the patient, the herding of people with all kinds and degrees of mental sickness on the same wards, the lack of simple decencies, the complete lack of privacy in overcrowded institutions, the contempt for human dignity.” Napa State Hospital in California was, he averred, a “grotesque mirage … [a] gingercake monstrosity … a dangerous firetrap.” In Detroit, “Many patients were strapped to their beds by leather thongs. Others sat rigid in chairs to which they had been bound hand and foot. Still others lay tightly wrapped up in ‘restraining sheets.’ Steel handcuffs restrained the movement of a large number of patients.”44
Deutsch concluded that “life in a mental hospital, all too often, is a never-ending nightmare.”45 At each of his visits, he had brought along a photographer, and these images provided powerful visual evidence of the horrors his text proclaimed. So here, at first blush, was a powerful indictment of institutional psychiatry. Yet superintendents had thrown open their doors to Deutsch. In some cases, they had personally toured the worst wards with him and his accompanying photographer. So, far from evading the scrutiny he promised to provide, they had positively encouraged the publication of his findings.
They knew their man. For Deutsch sought to use his exposé not to call for the abolition of state hospitals, but to secure huge amounts of new funding to turn them into the therapeutic institutions they purported to be. The conditions he had found were not, he insisted, the fault of the psychiatrists, but ultimately of the politicians and the public at large, both of whom had defaulted on their obligation to provide the amounts of money that humane and effective care necessarily cost. In a concluding chapter on the ideal mental hospital, Deutsch outlined the utopia that increased funding could create: new hospitals for no more than a thousand patients, located in or near urban areas, where easy links could be established with medical schools to bring science to bear on the problems of mental illness. “Maximum application will be made of Freudian psychoanalysis properly modified to meet the needs of psychotic patients.”46 And modern treatments—metrazol shock, ETC, insulin coma treatment, and frontal lobotomies, all in desperately short supply in extant mental hospitals—would be universally available and widely applied.
DEUTSCH AND HIS ALLIES were never able to muster the necessary political support for such a program. Instead, within a decade, as sociologists supported by grants from the new National Institute of Mental Health turned their attention to the state hospitals, a very different set of proposals began to circulate. The sociologist Ivan Belknap suggested in 1956 that mental hospitals “are probably themselves obstacles to the development of an effective program of treatment for the mentally ill” and that “in the long run the abandonment of the state hospitals might be one of the greatest humanitarian reforms and the greatest financial economy ever achieved.”47 It was a judgment echoed by many of his fellow sociologists, most notably the Canadian-American Erving Goffman, whose indictment of the asylum argued that the defects of these establishments were embedded in their very structure and thus could not be removed by any conceivable expenditure or reform. They were total institutions, akin to prisons and concentration camps—a comparison now made not by hyperbolic journalists but by sober social scientists. Far from sheltering and helping to restore the mentally disturbed to sanity, mental hospitals disabled and damaged their clientele.48
As the reputation of the mental hospital reached its nadir, institutional psychiatrists faced a bleak future. A diminished presence in their own profession, their claims to expertise and the legitimacy of their calling were under sustained assault. Their far better-remunerated colleagues practiced a very different type of psychiatry on patients who were in almost all respects more desirable, and they also distanced themselves as far as possible from the stigmatized, impoverished, and deeply disturbed psychotics their beleaguered counterparts struggled to cope with. So, far from the increased funding Deutsch and his allies had sought for asylums, states were displaying a growing skepticism about public psychiatry, a shift in sentiment that had begun to manifest itself in the declining number of patients residing in state hospitals on any given day. That decline was slow at first, though it was historically unprecedented since the birth of the asylum in the nineteenth century. But in the 1960s, it would begin to accelerate, and by the Reagan era, mental hospitals and public psychiatry were on the verge of disappearing.
Deinstitutionalization, as the abandonment of traditional mental hospitals came to be called, extended over several decades. The deaths of the asylum and of institutional psychiatry were drawn-out processes. Neither academic psychiatry nor the ever-larger fraction of practicing professionals who made their living from ambulatory patients showed any disposition to criticize, let alone oppose, what was happening. Surely, they concluded, care in the community would prove superior to the horrors of the barracks-asylum. Psychiatrists and their political masters seemed not to notice that both the community and the care were chimeras, as we shall see. So it was that an alternative version of malign neglect became public policy, dressed up in the raiment of reform.